Participant Certification. My signature on this form acknowledges that I have read, understand and agree to the SDO participation requirements above. I recognize that there may be changes to these requirements in the future. I will be notified of any major changes, and it is my responsibility to read and be aware of these. I have been provided and read the applicable brochures, available upon request, regarding the SDO and understand this information. SSN: Signed: Date: Return completed form to:
Participant Certification. By signing this Agreement below, Participant hereby certifies that, to the best of Participant’s knowledge, all of the information provided in the Application for Operation of Customer‐Owned Generation is true and correct, the Generator will comply with the Interconnection Agreement, and that Participant has received and reviewed this Agreement.
Participant Certification. I affirm that the information I have provided on this form is complete and accurate and is of my own free will.
Participant Certification. By signing below, I certify that the following are true and correct: • The investment is an eligible SIMPLE IRA rollover contribution being rolled over within 60 days. • The rollover does not include required minimum distribution amounts or corrective distribution amounts. I understand that this rollover contribution is irrevocable. I agree that I am solely responsible for all tax consequences. I also agree that neither the Custodian nor Pacific Funds shall have responsibility for any such tax consequences or any consequences resulting from this amount being ineligible for rollover. Rules regarding rollovers, and their tax implications, are complex. Please refer to IRS Publication 560 and 590 or a professional tax advisor for more information. I have read and understand and agree to be legally bound by the terms of this form. I also understand that the Custodian will rely of my certification when accepting my rollover contribution. SIGN HERE Participant’s Signature Date Supplement to the SIMPLE Individual Retirement Account (SIMPLE IRA) Disclosure Statement For Tax Year 2018 2019 SIMPLE IRA CONTRIBUTION LIMITS: The maximum allowable contribution to your SIMPLE IRA for tax year 2019 is 100% of your salary up to $13,000 as deferred compensation. This limit is in addition to your employer’s matching or non-elective contributions. In the case of an eligible employee who will be age 50 or older before the end of the calendar year, the above limitation is $16,000 for 2019. For tax years after 2019, the above limits may be subject to Internal Revenue Service (IRS) cost- of-living adjustments, if any. Please read the SIMPLE Individual Retirement Account Disclosure Statement carefully or consult IRS Publications 560 or consult a professional tax advisor for more information about eligibility requirements and contribution restrictions. SIMPLE INDIVIDUAL RETIREMENT ACCOUNT (IRA) DISCLOSURE STATEMENT The following information is the disclosure statement required by federal tax regulations. You should read this Disclosure Statement, the Custodial Account Agreement and prospectuses for the mutual funds in which your Savings Incentive Match Plan for Employees of Small Employers Individual Retirement Account (“SIMPLE IRA”) contributions will be invested. The rules governing IRAs are subject to change. You should consult Internal Revenue Service (“IRS”) Publications 560 and 590 or the IRS web site xxx.xxx.xxx for updated rules and requirements. IMPORTANT INFORMATION ABOUT ...
Participant Certification. Based upon training participation and training ratings and written examination scores, ToT participants will be classified into one of three categories: 1) Certified Trainer; 2) Co-Trainer; or 3)
Participant Certification. Email Address: Please Print Clearly Certification: I elect not to receive paper statements. I agree to carefully review my quarterly account statements online. I understand that I will receive an electronic notification that my statement, Quarterly Newsletter, and Individual Investment Performance have been posted to the web site and that I must provide an accurate email address. I agree to notify the Plan of any changes to my email address. I also understand I may elect to receive paper statements in the future by notifying the Administrative Service Agency in writing. If I do, paper statements will resume as soon as administratively possible and at no additional charge. I recognize that the New York State Deferred Compensation Plan has the authority to change my request and resume sending paper statements to my address of record. Participant Signature Date Return to: New York State Deferred Compensation Plan Overnight Address: New York State Deferred Compensation Plan 000 Xxxxxx Xxxx Xxxxxxxxxxxxxx Xxxxxxx Xxxxxx, XXXX-X0 Troy, NY 00000 0000 Xxxxxxxxx Xxxxx, Xxxxx X Grove City, OH 00000-0000 OR Fax to: 0-000-000-0000 When faxing paperwork, please allow two hours from receipt for it to be processed. If your fax is sent after 3 p.m. your paperwork will be processed on the next business day.
Participant Certification. I affirm that the information I have provided on this form is complete and accurate and is of my own free will. Participant’s Signature Date
Participant Certification. I have read, understand and agree to the above participation requirements. I recognize that there may be changes to these requirements. I will be notified of any applicable changes, and it is my responsibility to read and understand such changes. I acknowledge that I have been provided and I have read the applicable brochures available upon request, regarding the SDO and understand the information. SSN: Signed: Date: Return completed form to: Nationwide Retirement Solutions: P.O. Box 182797 Columbus, Ohio 43218-2797 Toll Free: 0-000-000-0000 Fax Number: 0-000-000-0000
Participant Certification. Each Participant issued a Card shall certify upon issuance and each plan year thereafter that the card shall only be used for Health Care Expenses. The Participant shall also certify that any expense paid with the Card has not already been reimbursed by any other plan or source, and that the Participant will not seek reimbursement under any other plan covering health benefits.
Participant Certification. I certify that check/voucher number __________ for $_______ has been issued on my behalf and that I have no other resources upon which to draw to pay for this/these item/s.
