1727Q59330PLL Personal Check Redeposit ... - Northern Trust

PERSONAL CHECK REDEPOSIT FORM ? Single Checks/Participants Please Attach Checks to This Form

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Date: __________________ Client Name: ________________________________ Client #_________ CSR Name ________________________________ Sender's Name: ______________________________ Phone Number: ( ________ ) _____________ __________________

ALL PERSONAL CHECKS SHOULD BE MADE OUT FOR THE NET AMOUNT OF PAYMENT RECEIVED

TO BE COMPLETED ONLY IF EXCESS REDEPOSIT APPLIES NOTE: If no box is selected, overages in the amount of $50.00 or less will be deposited directly into the trust.

However, if this check is greater than the net amount of the payment(s) below, The Northern Trust Company is instructed to: Deposit excess amount to the trust. Create a separate check for overpayment and send to:

Participant Estate of _________________________________________________________________________________

Address___________________________________________________________________________________________________

Note: All prior year redeposits initiated after the Yearend Final Recovery Date (as noted in the Important Processing Deadlines page) will have the Net amount less Tax Withholding redeposited back to the applicable trust(s).

Participant Name: ______________________________________________________________________________________________________________

Participant Reference ID: _____________________________ Plan Number: ________________________ Last 4 digits SS#: XXX-XX-__________

Personal Check #:_______________________ Date: _______________________________ in the Amount of $_______________________________

Please specify payment dates and applicable amounts to which this check should be applied:

Payable date mm/dd/yy

Net Amount

Personal Check Amount Total

$ 0.00

If your plan utilizes multiple funding sources, please indicate below the funding source(s) and applicable amounts to be used for the redeposits listed above: Funding Source ___________________________ $__________________________

Funding Source ___________________________ $__________________________

Funding Source ___________________________ $__________________________

Northern Trust is hereby directed to deposit these funds to the trust(s) applicable to the payment(s) stated above.

Authorized: ______________________________________________________________ Date: ___________________________________

Please Attach Check(s) and Mail To: The Northern Trust Company Benefit Payment Services W-38 50 South LaSalle Street Chicago, IL 60603

Q59330 (4/17)

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