in-service distribution of rollover account - New York State Deferred ...

HELPLINE: 1-800-422-8463WWW.NYSDCP.COMIN-SERVICE DISTRIBUTION OF ROLLOVER ACCOUNTPERSONAL DATA____________________________________________________________________________ ________________________Name (Please Print)Social Security Number____________________________________________________________________________ ________________________Home AddressDate of Birth____________________________________________________________________________ ________________________City State Zip Home Telephone Number____________________________________________________________________________ ________________________EmployerWork Telephone NumberROLLOVER INFORMATIONIf you have made rollover contributions to the Plan from more than one qualified retirement plan, please indicate from whichrollover contribution the requested distribution is to be made.Check Plan Type: 457(b) Qualified Plan IRA_____________________________________________________________________________________________Previous Plan Administrator_____________________________________________________________________________________________Current Approximate Account ValuePAYOUT METHODStep One: Type of Withdrawal (choose one) Full Withdrawal (Effective Upon Receipt) – Please proceed to Authorization sectionPartial Withdrawal $_________________(Effective Upon Receipt)Please proceed to Authorization sectionPartial Withdrawal followed by Periodic PaymentsPartial Withdrawal Amount:$_______________(Effective Upon Receipt) – Proceed to Step TwoPeriodic Payment OnlyStep Two: Fixed Time Period or Fixed Dollar Amount (choose one) Fixed Dollar Amount of $ _______Please note that if you are age 70 1/2 or older, you are required to receive a Required Minimum Distribution (RMD). Ifyour periodic payments do not meet your RMD, an additional check will be sent to insure you meet your RMD in thecalendar yearOR Fixed Time Period For a Fixed Time Period of _______ years (not to exceed life expectancy) Throughout My Life Expectancy Throughout Joint Life Expectancy of Myself and My SpouseNote: Uniform Life and Joint and Last Survivor Life Expectancy tables are prepared by the United StatesDepartment of the Treasury. Information regarding the life expectancy of a person of your age andsituation can be obtained by calling the HELPLINE at 1-800-422-8463 and speaking to a HELPLINERepresentative or Account Executive, or you can access the table on the Plan website at www.nysdcp.com.

The use of the Joint and Last Survivor Life Expectancy Table is limited to participants whose spouse is morethan ten years younger than the participant and the spouse is the sole beneficiary of record. If you haveselected benefit payments based on the Joint and Last Survivor Life Expectancy Table, please complete thefollowing:___________________________ _________________________ __________________________Spouse’s Name Spouse’s Date of Birth Spouse’s Social Security No.Step Three: Frequency (Note: If frequency is not selected, then it will default to a monthly payment)A. Frequency: B. Begin payments in _____________(month) to be Monthly received by (select one option below) Quarterly 1 st of the month 15 th of the month Semi-annually 5 th of the month 20 th of the month Annually 10 th of the month 25 th of the month Withdrawals to be made from Stable Option onlyStep Four: Tax WithholdingA. Federal WithholdingFor periodic distributions of less than ten years, Lump Sum and Partial Lump Sum distributions, the IRS requiresthe Plan to withhold 20% of the distribution. If you want the Plan to withhold a greater amount, please indicatethat amount below: Other – please indicate higher percentage amount ________% (must be a whole percentage)For distributions of 10 years or longer or to fulfill a Required Minimum Distribution, the IRS does notrequire a specific withholding rate. Please choose a Federal withholding rate: 10% Default tax withholding Other – please indicate percentage amount ________% (may be higher or lower than 10%, may be 0%)B. State WithholdingThe Plan is not required to withhold for state income tax purposes. If you want a portion of yourdistribution withheld for state income taxes, please complete the following: Indicate State ________ Indicate percentage amount ________%DIRECT DEPOSIT INSTRUCTIONSCheck only one option: Checking Account Savings Account_____________________________________________________________ ___________________Bank/Credit Union NameAccount NumberABA NUMBER (First nine digits only) I: /____/____/____/____/____/____/____/____/____/ I:Your ABA number appears at the bottom of your checks between the markings indicated above.Bank or Credit Union Telephone Number: ( )Note: Direct Deposit is only offered through members of the Automatic Clearing House (ACH).Is this account associated with a brokerage firm or other investment firm? Yes NoIf yes, have you confirmed that the ABA and account numbers are correct? Yes NoPlease note:You must include a voided check if your distribution is being sent to your checking account.Full withdrawals may not be received by direct deposit.

TRANSFER INFORMATION Transfer Assets to another Qualified Retirement Account(This option is only available to the former spouse of a participant)Name of Employer or Sponsor:___________________________________________________________________________________Make check payable to:__________________________________________________________________________________________For benefit of:________________________________________________________________________________________________(Note: Check will be sent to the Participant address on record with the NYSDCP Administrative Service Agency)I acknowledge that the individual named above is (a) an employee of the Employer named below, or (b) the owner of atraditional IRA or a conduit IRA at this institution.We sponsor a plan eligible under Internal Revenue Code 457(b), 401(a),401(k), 403 (b) or an Individual Retirement Account and the plan (sponsor) receives plan-to-plan transfers. Some mutual fundsmay impose a short-term trade fee. Please read the underlying prospectuses carefully.____________________________________________________________________________________Signature of Authorized Personnel from Accepting Rollover CompanyAUTHORIZATIONI understand I have a right to receive and review the Special Tax Notice Regarding Plan Payments no less than 30days and no more than 180 days prior to this distribution. However, if I elect to receive this distribution before theend of the 30-day minimum notice period, this election shall constitute a waiver of my rights to the 30-day noticerequirement.I attest that the information provided on this form is true and that I have received and read the Special Taxnotification that the Federal law requires not more than 180 days prior to requesting this distribution. I have read theinstructions and understand the requirements. I understand that I may be subject to civil and criminal liability forany false statement on this form or any papers attached to or related to this form or my claim under the Plan.I understand that the distributions of assets that were rolled in to the Plan from another qualified retirement plan oran IRA may be subject to an early distribution tax that would have applied to such plan, unless an exemptionapplies.If I have elected to have my distributions from the Plan be directly deposited, I hereby authorize the Plan’s trustee toinitiate such automatic deposits from the Plan to the account referenced above with the financial institution namedabove. This authority will remain in effect until I have given the Plan written notice that I have terminated theabove referenced account or until I have been notified that this deposit service has been terminated. I understandthat I must give the Plan sufficient advance notice to allow for processing of these instructions. If an incorrectamount should be entered into my account by the Plan, I authorize the Plan to direct my bank to make theappropriate credit or debit adjustment.____________________________________________________________Participant Signature______________________DateReturn to:New York State Deferred Compensation PlanAdministrative Service Agency, PW-04-08P.O. Box 182797Columbus, OH 43218-2797DC-4214-0111Overnight Address:New York State Deferred Compensation PlanAdministrative Service Agency5900 Parkwood Drive, PW-04-08Dublin, Ohio 43016