Participant Withdrawal/Direct Rollover Request Private Sector Operations

Participant Withdrawal/Direct Rollover Request Private Sector Operations

Page 1 of 3

Phone: 800-548-6436 ? Fax: 877-NF401ks (877-634-0157) ?

1. Purpose

Use this form when requesting a distribution from traditional or Roth sources of money for participant accounting or investment only plans when Nationwide? is designated the payor, and responsible for tax reporting the distribution. Use the Participant Withdrawal (457) for 457 plans.

2. Case information

Case Number: Case Name:

Does this case include multiple fixed contracts?

c Yes c No (If Yes, answer the next question)

Does the de minimis policy apply to this withdrawal?

c Yes c No (If No, complete Attachment B)

3. Participant information

Is the participant over 59 1/2? c Yes c No

Name: SSN:

Street Address:

City: State: Zip:

NOTE: Tax document will be mailed to the address specified unless alternate payee or beneficiary information provided.

4. Payee Information

Total number of Payees:

(Use a separate form for each payee)

Distribution Reason: Date of Death: (if reason is participant death)

Distribution is for: c Participant c Beneficiary

Beneficiary Information:

Name: SSN:

Street Address:

City: State: Zip:

Payee Method: c Direct Payment

c Direct Roll to Other Eligible Plan, IRA, or Roth IRA (Roth sources only)

c In-Kind transfer out for:

c SDB account (SDB assets that will be transferred in-kind must be 100% vested

c ER stock fund (non-taxable distributions only)

Payee Name: FBO:

Account #: Account # (Roth):

Street Address:

City: State: Zip:

PNN-1240AO.1 (4/2015)

Case Number:

5. Account/Tax Information

Page 2 of 3

Non-Resident Alien: Taxable distributions to non-resident aliens are subject to 30% withholding unless a valid IRS form W-8BEN containing an ITIN (individual taxpayer identification number) is submited to claim a reduced rate or withholding exemption that is available under a U.S. income tax treaty.

Is this a Puerto Rico Source Distribution? c Yes c No

Traditional Sources (1-20)

c Total OR c Partial Distribution Fund Source Amount $ Unit %

NOTE: If total distribution is marked above, and fund/source & amount are left blank we will process from all funds/ sources and 100% of balance. If partial is marked, fund/source/amount must be completed in order to be processed.

Total:

ccc ccc ccc ccc

0

IRS Distribution Code:

IRS Distribution Code for In-Kind Transfer:

Forfeit c Yes c No c Yes c No c Yes c No c Yes c No

Outstanding Loan (additional reportable): $ Distribution Code for Outstanding Loan:

Employee Contributions (Non-Taxable): $

Withholding: c None

c Federal Mandatory 20%

c Federal Elective

% or $

c State (if blank, Nationwide will calculate)

% or $

c State Additional

% or $

Special Instructions:

NOTE: A withholding selection (and amount, if applicable) must be completed for request to be processed.

Roth Sources (21-24)

c Total OR c Partial Distribution Fund Source Amount $ Unit %

NOTE: If total distribution is marked above, and fund/source & amount are left blank we will process from all funds/ sources and 100% of balance. If partial is marked, fund/source/amount must be completed in order to be processed.

21 22 23 24 Total:

ccc ccc ccc ccc

0

IRS Distribution Code:

IRS Distribution Code for In-Kind Transfer:

1st Yr. of Desig. CN.

EE Contrib. Amount

$

$

$

$

Outstanding Loan (additional reportable): $ Distribution Code for Outstanding Loan:

Employee Contributions (Non-Taxable): $

Withholding: c None

c Federal Mandatory 20%

c Federal Elective

% or $

c State (if blank, Nationwide will calculate)

% or $

c State Additional

% or $

NOTE: A withholding selection (and amount, if applicable) must be completed for request to be processed.

PNN-1240AO.1 (4/2015)

Case Number:

6. Fees

Page 3 of 3

CDSC:

Does a CDSC/Termination Charge Apply? c No c Yes, Complete CDSC/Term Charge sheet

In-Kind:

A $100 fee applies to each in-kind transfer distribution.

Investment Only:

PPA and Nationwide fees will be taken in addition to the withdrawal amount specified.

Participant Accounting: PPA and Nationwide fees will be netted from the distribution when taking 100% of the participant's.

Redemption Fee for Some of the funds in this plan may have redemption fee policies. This transaction may be Participant Accounting: subject to redemption fees. Please review the Trading Policy List for more details.

PPA/TPA Fee:

Plan Administrator Withdrawal Fee apply? c No c Yes, Amount: $

Show PPA Fees on Check?

c No c Yes (if blank, No is assumed)

7. Payment Method

c Wire c ACH

Account Type*: c Checking c Savings

Receiving Bank Name:

City: State:

Zip:

ABA (Routing)#:

Account #:

c Check

Mail to: c Plan Administrator c Participant c Payee c Plan Sponsor c Other (enter address below)

Street Address:

City: State:

Zip:

Shipping Method**: c U.S. Mail

c UPS Next Day Air

c UPS Next Day Saver

c UPS 2nd Day Air

c UPS 2nd Day Air A.M.

*only required for ACH. If not provided, Nationwide will default to Checking.

**if no shipping method is selected, Nationwide wil default to U.S. Mail.

UPS Account No.:

8. Authorization

Authorized Representative Name (Please Print): Authorized Representative Signature: Date:

The Nationwide? Group Retirement Series includes unregistered group fixed and variable annuities and trust programs. The unregistered group fixed and variable annuities are issued by Nationwide Life Insurance Company. Trust programs and trust services are offered by Nationwide Trust Company, FSB a division of Nationwide Bank?. Nationwide Investment Services Corporation, member FINRA. Nationwide Mutual Insurance Company and Affiliated Companies, Home Office: Columbus, OH 43215-2220

Nationwide, the Nationwide N and Eagle and Nationwide is on your side are service marks of Nationwide Mutual Insurance Company. ?2015 Nationwide

PNN-1240AO.1 (4/2015)

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download