SEAFARERS MONEY PURCHASE PENSION PLAN
▪ 5201 Auth Way ▪ Camp Springs, Maryland 20746 ▪ (800) 252-4674 (option 6) or (301) 899-0675
APPLICATION FOR PENSION BENEFIT
This form is for pension benefits only. If you want to apply for another benefit, you must use a different application form.
Please call the Plan office to request the proper application form.
Please read this application carefully before answering any questions. Print your answers to all questions which apply to you. If any part of
the application is not clear, please contact the Plan office for assistance, at the above phone number between 9:00 a.m. and 5:00 p.m.
EST, Monday through Friday.
I hereby make application for benefits from the Seafarers Money Purchase Pension Plan. I make the following statements and
representations to the Trustees of the Fund with the knowledge that they will rely on this information in approving payments.
1
Participant’s Name __________________________________________________________________________________________
FIRST
2
MIDDLE INITIAL
LAST
Address __________________________________________________________________________________________________
NUMBER AND STREET
CITY
STATE
3
Social Security Number ________/_______/________
5
Date of Birth ________/_______/________ (Submit birth certificate if monthly Joint and Survivor Benefit is chosen)
6
Marital Status:
___ Single
4
ZIP CODE
___ Married
Phone Number (
) _____________________________
___ Divorced
___ Widowed
(Submit marriage certificate) (Submit Divorce Decree/QDRO)
7
Spouse’s Name __________________________________
(Submit Death Certificate)
Spouse’s Date of Birth ________/_______/________
(Submit birth certificate if monthly Joint and Survivor Benefit is chosen.)
8
Union Affiliation
__ SIU
__ SMU
__ UIW
__ SEATU
__ NMU
__ GLTD
Type of Benefit – Please check Account(s) you wish to receive money from and indicate Date of Event.
9
Employer Contribution Account
A
_____
Choose Type:
_____
Normal Retirement
______________ Date of Retirement
▪ Age 65 – deep sea; Age 62 – Inland or other covered employees.
▪ Proof of cessation of employment in the maritime industry required by signing Cessation of Employment declaration.
_____
Early Retirement
______________ Date of Retirement
▪ Age 55 provided the participant has been an Employee for a minimum of 20 years.
▪ Proof of cessation of employment in the maritime industry required by signing Cessation of Employment declaration.
_____
Total and Permanent Disability
_____
Withdrawal Benefit
______________ Date of Retirement (Submit Social Security Disability Award)
▪ Proof of cessation of employment in the maritime industry required by signing Cessation of Employment declaration.
▪ Must be out of the industry for at least twelve (12) consecutive months
B
Election of Benefit Form
▪ If your account balance is less than $5,000, it will be paid to you in one lump sum payment.
▪ If balance is $5,000 or more, you may elect the form of payment listed below.
Choose One:
_____
One Lump Sum Payment (20% Federal Withholding Tax Applies)
_____
Ten (10) Equal Annual Payments
_____
Monthly Joint & 50% Survivor Benefit * OR Monthly Joint & 75% Survivor Benefit *
▪ Both Joint & Survivor Benefits may be paid in the form of monthly payments for the joint lives of you and your spouse. The
monthly payments are based upon your account balance and the ages of you and your spouse. If you are interested in this
option, please check the J&S box and submit application with a copy of both birth certificates. The Plan will then provide
you with an estimate of your monthly benefit under the Joint & Survivor benefit options prior to processing your application.
_____
Direct Rollover to another Qualified Plan
▪
You must provide Rollover information on next page along with a rollover authorization form signed by you and a
representative of the company you are sending your money to.
Notice of Withholding – Any money paid directly to you from your Employer Contribution Account will be subject to a mandatory 20% Federal
Withholding Tax. The only exceptions to this law are payments over a period of at least 10 years in length or a rollover of the money to another
Tax Deferred Qualified Retirement Plan. Any money paid directly to you from your Voluntary Contribution Account will be subject to a 20%
Federal Withholding Tax calculated on the interest earned on the account. The only exceptions are payments over a period of at least 10 years in
length or a rollover of the money to a post-tax account such as a Roth IRA.
HBP 026 – 12/2014
SEAFARERS MONEY PURCHASE PENSION PLAN
▪ 5201 Auth Way ▪ Camp Springs, Maryland 20746 ▪ (800) 252-4674 (option 6) or (301) 899-0675
APPLICATION FOR PENSION BENEFIT – Page 2
10
If you Choose a Rollover from 9 B (on the other side of application), or Item 11 B (below, complete this item.
________________________________________________________
( _ )______________________________________
NAME OF BANK OR FINANCIAL INSTITUTION
PHONE NUMBER
______________________________________________________________________________________________________
STREET ADDRESS OF BANK OR FINANCIAL INSTITUTION
______________________________________________________________________________________________________
CITY, STATE, AND ZIP CODE OF BANK OR FINANCIAL INSTITUTION
11
________________________________________________________
__________________________________________
CONTACT / ACCOUNT REPRESENTATIVE
ACCOUNT NUMBER
Voluntary Contribution Account _____
▪ Payout benefit available once every 18 months.
A
Election of Benefit Form
▪ You may elect the form of payment listed below:
Choose One:
_____ One Lump Sum Payment (20% Federal Withholding Tax Applies)
▪ Of Voluntary Contribution Account Balance;
_____ One Lump Sum Payment – Partial Withdrawal (20% Federal Withholding Tax Applies)
▪ A partial withdrawal from your Voluntary Contribution Account in the amount of $________________________
_____
Ten (10) Equal Annual Payments
_____
Direct Rollover to another Qualified Plan (post-tax account such as a ROTH IRA
▪ You must provide Rollover information on next page along with a rollover authorization form signed by you and a
representative of the company you are sending your money to.
ALL APPLICANTS MUST COMPLETE THE SECTIONS BELOW.
12
Spousal Consent:
A
If you are single, check here: _____
B
If you are married, and you are applying for a benefit from your Employer Contribution account in the amount of $5,000 or
more, or you are applying for a payout benefit from your Voluntary Contributions account, or you are applying for a rollover,
your spouse must complete the following:
I, _____________________________________________, born ____________________________, am aware that my spouse,
PRINT SPOUSE’S NAME
DATE OF BIRTH
_______________________________________________, has applied for his/her pension benefit, and/or a payout benefit
PRINT MEMBER’S NAME
from his/her voluntary contribution account. I understand that my spouse may be able to receive his/her benefits in the form of
a joint and survivor annuity. By signing this application, I consent to my spouse’s election regarding the form in which benefits
will be paid.
_______________________________________________
___________________________________
SPOUSE’S SIGNATURE
13
NOTARIZATION:
DATE SIGNED
STATE OF ______________________________, COUNTY OF: __________________________
I certify that on ______________________, 20_____, _____________________________ and _____________________________
DATE
APPLICANT’S NAME
Personally came before me and acknowledged under oath, to my satisfaction that (he/she):
a)
b)
is named in and personally signed this document; and,
signed, sealed, and delivered this document as (his/her) act and deed.
____________________________________________
A NOTARY PUBLIC
HBP 026 – 12/2014
SPOUSE’S NAME (if applicable)