SEAFARERS MONEY PURCHASE PENSION PLAN
▪ 5201 Auth Way ▪ Camp Springs, Maryland 20746 ▪ (800) 252-4674 (option 6) or (301) 899-0675 ▪
APPLICATION FOR IN-SERVICE PENSION BENEFIT OR REQUIRED MINIMUM DISTRIBUTION
This application is for active participants age 70 and over who are still working. You can apply to receive either your entire
account balance or to receive only the required minimum distribution. 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
this 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
___ Married
4
ZIP CODE
Phone Number ( __ )____________________
___ Divorced
___ Widowed
(Submit marriage certificate) (Submit Divorce Decree/QDRO)
7
Spouse’s Name _______________________________
Spouse’s Date of Birth
(Submit Death Certificate)
__________/_________/_________
(Submit birth certificate if monthly Joint and Survivor Benefit is chosen.
8
Union Affiliation
__ SIU
__ SMU
__ UIW
__ SEATU
__ NMU
__ GLTD
Complete the section below ONLY FOR: REQUIRED MINIMUM PARTIAL DISTRIBUTION
9
Employer Contribution Account and Voluntary Contribution Account ____
A
_____
Mandatory Minimum Distribution
▪ This amount is determined by the Plan’s Actuary.
Complete the section below ONLY FOR: ELECTIVE DISTRIBUTION OF THE ENTIRE ACCOUNT
10
Employer Contribution Account
A
____ ▪ In-Service Distribution benefit for participants Age 70 and over who are still working.
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; Mandatory minimum distribution may
also be applied first)
______
Direct Rollover to another Qualified Plan (Mandatory minimum distribution may also be applied first)
▪ You must provide Rollover information in Item 12 along with a rollover authorization form signed by you and
a representative of the company you are sending your money to.
11
Voluntary Contribution Account
A
____ ▪ This is a payout benefit for participants Age 70 and over who are still working.
Election of Benefit Form
▪ You may elect the form of payment listed below.
Choose One:
______
One Lump Sum Payment of Voluntary Contribution Account Balance in the amount of $_____________
▪ 20% Federal Withholding Tax Applies
______
Direct Rollover to another Qualified Plan (post-tax account such as a ROTH IRA)
▪ You must provide Rollover information in Item 12 along with a rollover authorization form signed by you and
a representative of the company you are sending your money to.
HBP 027 - 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 IN-SERVICE PENSION BENEFIT OR REQUIRED MINIMUM DISTRIBUTION - Page 2
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 exception to this law is 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 exception is a rollover of the money to a post-tax account such as a Roth IRA.
12
If You Choose a Rollover from Item 10 A or 11 A above, 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
_____________________________________________
____________________________________________
CONTACT/ACCOUNT REPRESENTATIVE
ACCOUNT NUMBER
ALL APPLICANTS MUST COMPLETE THE SECTIONS BELOW.
13
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
14
NOTARIZATION:
DATE SIGNED
STATE OF __________________________, COUNTY OF: ______________________
I certify that on __________________, 20______, ____________________________
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 027 - 12/2014
SPOUSE’S NAME (if applicable)