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I.A.T.S.E. Annuity FundWithdrawal/Notice of Termination/Retirement/Disability FormThis form is used for requesting withdrawals (other than hardship withdrawals) or a distribution from theI.A.T.S.E. Annuity Fund. The form must be returned to the Fund Office, which will verify that all information isaccurate and complete and forward your request for processing. If you have any questions regardingthis form, please contact the Fund Office at 212-580-9092 or 800-456-FUND (3863).Participant InstructionsSection IComplete all applicable information.Section IIPlace a check in the box next to the reason for the distribution or withdrawal.Section IIIPlace a check in the box indicating either the amount of funds you are requesting or themaximum amount available. If you are requesting a specific dollar amount, pleaseindicate the amount. Place a check in the box that indicates how you would like thedistribution to be disbursed.Section IVIf you are choosing an annuity or a rollover of all or part of your account is selected inSection III, complete the information requested in this section.Section VIf applicable, attach or note any additional instructions that may be required to facilitatethe processing of your distribution.Section VIIndicate your Federal and State Income Tax withholding elections.Section VIISelect the method of paymentSection VIIIYou must sign this section as authorization of the distribution or withdrawal requested tofacilitate the processing of your distribution. You must also certify that the appropriateDistribution Election Notice and Special Tax Notice have been provided and areunderstood.Section IXWaiver of Joint and Survivor Annuity and Joint and Survivor Notice and Explanation: If yourbalance (excluding rollover contributions) is over 5,000, you (and your spouse, if married)must complete the waiver form unless you are electing a Life Annuity, or, if married, aQualified Joint & Survivor Annuity.Section XI.A.T.S.E. Annuity Fund Representative Instructions. The I.A.T.S.E. Annuity FundRepresentative must sign the form as authorization that the request is accurate andcomplete. Note: Instructions are subject to change based on Plan rules.Section XISpecial Tax NoticeReturn completed forms to:I.A.T.S.E. Annuity Fund, 417 Fifth Avenue, 3rd Floor, New York, NY 10016Fax: 212-792-8323593204 (Rev 03 – 08/16)Page 1 of 12
CLEAR*If this form is not complete, this will cause a delay in processing. Please print clearly.Call 212-580-9092 or 800-456-FUND (3863) with questions on completing this form.Section I – Participant InformationPlan NamePlan CodeI.A.T.S.E. Annuity FundWF000IATParticipant Name (print)Social Security NumberMarriedUnmarriedDivorced (must submit a divorce decreeand/or property settlement)Mailing AddressFund Office I.D. NumberCityDate of BirthStateHome Phone NumberEmail AddressCell Phone NumberZIP CodeLegal State of Residence**Alternate Email Address**If the Legal State of residence is not provided, the information provided in the mailing address will be used for state tax purposesSection II – Reason for Withdrawal (Select one of the following options)Termination of Employment (Before age 55)Rollover Contribution WithdrawalNormal Retirement (Age 65 or older)DisabilityAge 59.5 withdrawal (salary deferrals only if still working)Early Retirement (Age 55 to 64)Alternate Payee under a qualified domestic relations order(QDRO)Section III –Payment ElectionParticipants with account balances below 5,000 (excluding rollover contributions) can only select a lump sumpayment or Direct Rollover and are not subject to spousal consent requirements. If your balance (excluding rollovercontributions) is over 5,000 and wish to elect payment in the form of an annuity, see Section IV, below.Payment Amount: (Select one of the following options.)Distribute the total account balance or the maximum available.Distribute this amount: .Lump Sum Election: (Select one of the following options. Unless you request otherwise, lump sumdistributions are paid from after-tax money first and then from pre-tax money.)Entire lump sum payment to meDirect Rollover to an IRA or Qualified PlanPartial lump sum payment to me in the amount of balancePartial Direct Rollover in the amount of balance; direct rollover of the remaining distribution; lump sum payment to me of the remaining distributionNote: Complete the Direct Rollover Information section below for all elections that include a rollover request.Return completed forms to:I.A.T.S.E. Annuity Fund, 417 Fifth Avenue, 3rd Floor, New York, NY 10016Fax: 212-792-8323593204 (Rev 03 – 08/16)Page 2 of 12
Section IV – Direct Rollover / Annuity Provider Information If you turned age 70½ on or after 1/1/2010, the required minimum distribution portion of your distribution will be paiddirectly to you (less 10% withheld for federal income tax) and will not be rolled over. The same applies if you turned age70½ before 1/1/2010 and you cease to be employed.Qualified Joint & Survivor Annuity: A survivor annuity purchased from a company selected by the Trustees.Complete rollover section below. A 50% or 75% joint and survivor annuity.Life Annuity: An annuity contract purchased from a company selected by the Trustees.If you elect either Annuity option the Fund Office will contact you with more details.Pre-Tax Amounts Eligible for Rollover (Select one of the following options.)Wells Fargo Advisors Brokerage IRAAccount Number:Wells Fargo IRAAccount Number:Rollover to another financial institution:Name of Financial Institution, Trustee or CustodianName of Qualified Plan (if applicable)For the Benefit of (FBO)Account NumberDTC Number (if applicable)Rollover AddressCityStateZIP CodeAfter-Tax Contributions Eligible for Rollover (If applicable, select one of the following options.)Note: If you leave this section blank, the after-tax funds will be processed using the instructions provided in the Pre-Tax Rolloversection. Always verify that the receiving IRA, Qualified Plan, Section 403(b) Plan, or Governmental 457 Plan will accept therollover of your after-tax contributions.Cash payment to meRollover my after-tax contributions to the same account as my pre-tax amounts.Convert my after-tax contributions to a Roth IRA.Section V – Special InstructionsSection VI – Tax Withholding - Please read the “Special Tax Notice” that is included with thisapplication. Contact your tax advisor or the IRS if you have any questions concerning tax withholding.Federal 20% Federal Income Tax will be imposed on the taxableamount of any monies eligible for rollover to an eligibleretirement account. You may be liable for an early withdrawal penaltyimposed by the IRS.StateSome states require withholding to cover the StateIncome Tax and Wells Fargo complies with thoselaws. You may specify a dollar amount or a percentage towithhold for state taxes. However, for some states,mandated tax withholding might override specificelections. Do NOT withhold Federal income taxes.Do NOT withhold State income taxes.Withhold Federal income taxes.Withhold Withhold WithholdWithholdfor Federal income taxes.for State income taxes.% for State income taxes.% for Federal income taxes.Return completed forms to:I.A.T.S.E. Annuity Fund, 417 Fifth Avenue, 3rd Floor, New York, NY 10016Fax: 212-792-8323593204 (Rev 03 – 08/16)Page 3 of 12
Section VII – Method of PaymentSend payment by check – allow up to 10 business days for postal service delivery.ACH Direct Deposit to my bank account – deposited within 3 business days from date of processing.The Direct Deposit option is NOT available for RolloversACH (Automated Clearing House) Set-upBelow is the ACH set-up form that will allow Wells Fargo to deposit your withdrawal or distribution directly into yourchecking or savings account. Outlined below are the steps to complete the form. If you have any questionsregarding this form please contact the Wells Fargo Retirement Service Center at 866-728-3357.1.Please write clearly and legibly to avoid rejection of the form which could delay the processing of withdrawal.2.Complete the form and attach a voided check for a checking account or a blank preprinted deposit slip for asavings account. This is necessary to complete the ACH set-up.3.Check the box for direct deposit to checking or savings account.4.Complete the Depository Institution, ABA Transit Routing Number and Account Number. The ABA TransitRouting Number and Account Number can be found at the bottom of a check with the Account Numberfollowing the ABA Routing Number. The Account Number can be up to 10 digits. Please ignore the last groupof numbers; this is your actual check number which is not necessary.5.Please sign and date the form.6.I understand that if I do not fully complete this section or the bank account information I have provided isinvalid, a check will be mailed. Subsequent withdrawals will be processed in the same manner (up to 180days from the date of the original distribution) unless I notify Wells Fargo in writing to distribute the moneydifferently. I also authorize Wells Fargo to initiate a debit to my account for any overpayment or paymentsmade in error.The undersigned authorizes and directs Wells Fargo Institutional Retirement and Trust (“the Center”) to electronicallydeposit recurring distributions from the retirement plan listed above to the designated checking or savings account ofthe undersigned (“Account”).The undersigned further authorizes and directs the Center to debit or credit the Account for the purpose of adjustingerrors in amounts distributed. This authorization revokes all prior disbursement authorizations. The undersignedunderstands the Center reserves the right to cancel this agreement with prior notice, and the plan participant maycancel this authorization by providing written notice of cancellation to the Center at the address listed above not lessthan 30 days prior to the effective date of the cancellation. Direct Deposit to Checking AccountDepository Institution Direct Deposit to Savings AccountABA Transit Routing Number (9 Digits)Account NumberParticipant’s/Account Holder’s SignatureDateJoint Account Holder’s SignatureDateFor checking, attach a voided check. For savings, attach a preprinted deposit slip.Return completed forms to:I.A.T.S.E. Annuity Fund, 417 Fifth Avenue, 3rd Floor, New York, NY 10016Fax: 212-792-8323593204 (Rev 03 – 08/16)Page 4 of 12
Section VIII – Participant AuthorizationI hereby irrevocably request and consent to a distribution from my account on the terms stated above. I have readand received the Qualified Joint and Survivor Notice and Explanation and Special Tax Notice regarding plan payments.Under penalties of perjury, I certify that the information on this form is correct and my social security number shownon this form is my correct taxpayer identification number. I also certify that any eligible retirement plan specifiedabove meets all applicable requirements and will accept the direct rollover indicated.I understand that I have a right to a 30 day election period. I further acknowledge that I am waving the 30 dayelection period by making an affirmative election on this distribution form.I understand if all required items are not completed on this form, payment will be delayed.Participant or Beneficiary SignatureDateReturn completed forms to:I.A.T.S.E. Annuity Fund, 417 Fifth Avenue, 3rd Floor, New York, NY 10016Fax: 212-792-8323593204 (Rev 03 – 08/16)Page 5 of 12
Section IX – Waiver of Joint and Survivor AnnuityGeneral InformationIf your account balance is more than 5,000, your distribution is subject to a joint and survivor annuity requirement in yourretirement plan that must be waived by you, and if you are married, your spouse must consent to the waiver. Please review theattached Qualified Joint and Survivor Annuity Notice and Explanation for more information. Instructions for Completing this FormYou, the Participant, must complete Section A - ELECTION TO WAIVE JOINT AND SURVIVOR ANNUITY. Your spouse must complete Section B - SPOUSE'S CONSENT TO WAIVER. (IMPORTANT NOTE: The spouse's signature mustbe witnessed by a Notary Public or an authorized representative of the Annuity Fund.) If a Spouse's consent is not necessary for any of the reasons listed under Section C - SPOUSAL CONSENT TO BENEFITELECTION NOT NECESSARY, please complete Section C. Your completed form will then be submitted to your I.A.T.S.E. AnnuityFund Representative for approval. If a Spouse's consent is not needed for any other reason, please contact your I.A.T.S.E. AnnuityFund Representative directly for instructions on how to proceed.Section AELECTION TO WAIVE JOINT AND SURVIVOR ANNUITYTo (Plan Name): I.A.T.S.E. Annuity FundFrom:PARTICIPANT’S NAMESocial Security Number:As a participant in the above noted Plan, I hereby acknowledge that:a. The Plan provides that upon my retirement, my accrued benefit will be paid to me as an annuity – a life annuity if I am singleand a joint and survivor annuity if I am married. The amount of such annuity will be the amount that can be purchased froman insurance company with your account balance.b. I have the right to waive that form of payment, provided that if I am married my spouse consents to my waiver;c. I understand the terms of the life annuity and joint and survivor annuity and the financial effect of a waiver; andd. I may revoke a waiver at any time before benefit payments commence.Fully understanding the above, I hereby elect to waive the annuity form of payment provided by the Plan.EXECUTED thisday of,WITNESS.PARTICIPANTI,, a Notary Public, certify thatpersonally came before me this day and acknowledged being the spouse ofand signed this consent. I hereby witness the spouse’s signature.WITNESS my hand and seal, this(NOTARY SEAL)day of,.NOTARY PUBLICSection BSPOUSE'S CONSENT TO WAIVERI hereby consent to the foregoing election executed,, by my spouse to waive havingINSERT DATEbenefits under the Plan paid to the two of us in the form of a joint and survivor annuity. I hereby acknowledge that I understandthat:a. I will not receive annuity payments to which I would be entitled under the Plan if I survived my spouse;b. My spouse’s waiver is not valid unless I consent to it; andc. My consent is irrevocable unless my spouse revokes the waiver.SIGNED thisSTATEday of,COUNTYI,.SPOUSE’S SIGNATURE, a Notary Public, certify thatpersonally came before me this day and acknowledged being the spouse ofand signed this consent. I hereby witness the spouse’s signature.WITNESS my hand and seal, thisday of,.(NOTARY SEAL)NOTARY PUBLIC593204 (Rev 03 – 08/16)Page 6 of 12
Qualified Joint and Survivor Annuity Notice and ExplanationThis notice provides information to you about your distribution options under the Plan. Annuity forms of benefitdescribed in this notice will be provided by purchasing an annuity contract from an insurance company selected bythe Trustees with your account balance. Your benefits will be paid to you in the normal annuity form at the timesprovided for in the Plan, unless you elect to waive the form of benefit (with your spouse's consent if you aremarried). If you are not married, your normal form of benefit will be a Single Life Annuity. If you are married, theQualified Joint and Survivor Annuity (with a 50% or 75% annuity) will be your normal form of benefit. Your planalso provides an optional lump sum and partial lump sum forms of payment. Because the annuity will be purchasedwith your account balance, the value of the annuity benefit is equal to your account balance.Qualified Joint and Survivor AnnuityThe Qualified Joint and Survivor Annuity payment form (QJSA) provides you with an annuity for your life, and asurvivor annuity for the life of your spouse that is 50% or 75% of the amount payable while both you and yourspouse are alive. Should you predecease your spouse, your spouse will receive this survivor benefit for the rest ofhis or her life.You and your spouse will receive benefits from the Plan in the QJSA payment form unless you choose a differentpayment form and your spouse consents to the choice. If your spouse consents to change the way the Plan'sretirement benefits are paid, your spouse gives up his or her right to the QJSA payments. This is referred to as a"waiver" of the QJSA payment form. Other payment forms may give you a larger retirement benefit while you arealive, but your spouse, as a result, may receive a smaller benefit or no benefit at all, after you die.If your spouse signs the Waiver of Qualified Joint & Survivor Annuity, they are agreeing that the benefits under thePlan will be paid in the payment method elected on the form. If you elect to name a beneficiary other than yourspouse (with your spouse’s consent), the beneficiary will receive all or part of the survivor benefits from the Planafter you die. You cannot change the payment form unless your spouse agrees to the change by signing a newagreement or has waived that right. However, you can change and elect the QJSA payment form without gettingyour spouse's approval.If your Plan allows it, you may change or revoke your election if made within the 30- to 180-day election periodending on your retirement date.Also, if you become legally separated or divorced after making your election but before payments begin, this mayend your spouse's right to survivor benefits from the Plan. However, if you become legally separated or divorced,you and your spouse may split your benefit, through a special court order called a Qualified Domestic RelationsOrder or QDRO. A QDRO would give your spouse rights to receive retirement benefits. If you are thinking aboutseparating or getting a divorce, you should get legal advice on your rights from the Plan.If you are not married, the normal form of benefit is a Single Life Annuity. A Single Life Annuity is described underOptional Forms of Benefit.Optional Forms of BenefitFollowing are descriptions of some other forms of benefit. If you are married, your spouse will have to consent toany of these alternatives you choose.Lump Sum Cash PaymentYou may take some or all of the money in your account as a cash payment. However, unless you directly rolloveryour payment to an IRA or another employer sponsored plan, the payment will be subject to immediate taxation. Ifthe payment is made to you, 20% will automatically be withheld as prepayment of federal income taxes. Inaddition, the payment may be subject to additional federal taxes, depending on your tax bracket, state and localtaxes, as well as an early withdrawal penalty if you are under age 59.5. If you take your entire account balance as acash payment, you will not receive any other payments from the Plan.Single Life AnnuityA Single Life Annuity provides guaranteed monthly payments for your life. Upon your death, payments stop. Annuitypayments under a Single Life Annuity will be larger than any other form of annuity offered under the Plan. However,no benefit is paid to a beneficiary.Return completed forms to:I.A.T.S.E. Annuity Fund, 417 Fifth Avenue, 3rd Floor, New York, NY 10016Fax: 212-792-8323593204 (Rev 03 – 08/16)Page 7 of 12
Section CSPOUSAL CONSENT TO BENEFIT ELECTION NOT NECESSARYThe undersigned participant in the Plan hereby certifies that the distribution option elected, does not require a spousal consent forthe following reason (select one):I am currently not married and there are no Plan benefits payable to a former spouse under a Domestic Relations Order(Submit copy of divorce decree if divorced)I cannot locate my spouse (Contact the Fund Office for proof requirement)I am legally separated, as confirmed by court order (submit a copy of court order)I have been abandoned by my spouse as confirmed by court order (submit a copy of court order)PARTICIPANT’S SIGNTUREDATESection X – For Fund Office AuthorizationReview the form, complete this section and forward the form to Retirement Services.TO BE COMPLETED BY YOUR I.A.T.S.E. ANNUITY FUND REPRESENTATIVE:Reason f
I.A.T.S.E. Annuity Fund, 417 Fifth Avenue, 3rd Floor, New York, NY 10016 Fax: 212-792-8323. 593204 (Rev 03 – 08/16) Page 3 of 12 Section IV – Direct Rollover / Annuity Provider Information If you turned age 70½ on or after 1/1/2010, the required minim
