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UFMCC BOARD OF PENSIONS (USA)BENEFIT PAYMENT ELECTION FORMPlease consult your tax advisor first.Please pay my retirement benefit to me as follows (initial one);____ A Single Sum Cash Payment.____ An Annuity Policy which will provide monthly payments for life. (For the life of the annuitant ONLY. There is no survivor benefit.)____ Direct Rollover to an Individual Retirement Account that I have already set up. (Note: If you elect to rollover all or any portion of your retirement benefit, you must obtain the necessary approval from your sponsor or trustee of the recipient IRA. The check will be mailed directly to that financial institution where the IRA is set upI elect to rollover ALL or $__________ of my distribution to the IRA indicated below;Name of Financial Institution: _______________________________________Mailing Address: __________________________________________________Account Number: ______________ Contact Person’s e-mail:_______________This election remains valid until revoked. I understand that I make revoke or change this election any time prior to my actual distribution of benefits._x________________________________________x_______________________ Participant’s signature Date signedCURRENT INFORMATIONName ______________________________Address ___________________________________________________________City, State, Zip code _________________________________________________Primary phone _________________________ Other ______________________Email Address __________________________ SS# _______________________UFMCCP O Box 50488Sarasota, FL 34232 ................
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