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GENERAL INSTRUCTIONS FOR QUALIFIED PLAN DISTRIBUTIONSIMPORTANT INFORMATIONBefore proceeding, contact your employer’s Plan Administrator to discuss your distribution options and to obtain theirauthorization for distribution.In addition, it is important that you read the Rollover Explanation For Qualified Plans and 403(b) Plans - Special Tax NoticeRegarding Plan Payments included in this booklet.To request a distribution from a Profit Sharing or Money Purchase Pension Plan custodial account, you must complete:Form A - Participant’s Request for a Qualified Plan Distribution in its entirety for all distribution requests (except required minimumdistributions, see below).Direct Rollover: - If you have met the qualifications for a distribution and are electing to roll the proceeds directly into an individualretirement account, 403(b) or other qualified plan account, please complete:Form A - Participant’s Request for a Qualified Plan Distribution, andForm B - Qualified Plan Direct Rollover/Affirmative Election Form (include a completed W-9 if requesting a surviving spouse directrollover)Note: Please refer to the Rollover Explanation For Qualified Plans and 403(b) Plans - Special Tax Notice Regarding Plan Payments for rollover rules.Qualified Domestic Relations Order (QDRO):Form A - Participant’s Request for a Qualified Plan Distribution, andForm B - Qualified Plan Direct Rollover/Affirmative Election FormInclude a certified copy of the QDRO and a completed W-9Required Minimum Distributions:Form C - Qualified Plan Required Minimum Distribution Election FormPlease note: This booklet is 11 pages in its entirety, and consists of three separate forms and a special tax notice. Different formsare required depending upon the type of distribution you are requesting. Please be sure to print and complete all pages of eachform needed for your distribution type. You must return the appropriate completed forms as identified in the instructions above toavoid processing delays.Important Information for Non Resident Aliens: In the absence of a tax treaty exemption, nonresident aliens, nonresident alien beneficiaries, and foreign estates generally aresubject to a 30% federal withholding tax on the taxable portion of periodic or nonperiodic pension payments from U.S. sources. For details, see Publication 515, “Withholding ofTax on Nonresident Aliens and Foreign Entities”, and Publication 519, “U.S. Tax Guide for Aliens”. A foreign person should submit Form W-8Ben, “Certificate of Foreign Status ofBeneficial Owner for United States Tax Withholding” along with their request. See page 4 of the Rollover Explanation For Qualified Plans and 403(b) Plans - Special Tax NoticeRegarding Plan Payments.
Voya Investment ManagementP.O. Box 9772Providence, RI 02940-97721-800-992-0180FORM A - PARTICIPANT'S REQUEST FOR A QUALIFIED PLAN DISTRIBUTIONPlease read the Rollover Explanation For Qualified Plans and 403(b) Plans - Special Tax Notice Regarding Plan PaymentsPARTICIPANT INFORMATIONParticipant Name:Account Number:Address:City:State:Zip Code:Social Security Number:Date of Birth:Telephone Number:Name of Employer:Employer’s Plan Name:MARITAL STATUS OF PARTICIPANTI certify that I am not married(Participant's initials).I certify that I am married (Participant's initials). Spouse's Name:Spouse's Birth Date:QUALIFIED JOINT AND SURVIVOR ANNUITY (QJSA) NOTICE (contact your Plan Administrator to determine if this applies to you)The Retirement Equity Act of 1984 requires that the form of benefits under certain plans satisfy specific rules. If you are married and participating in this type of plan,Federal law may require that you receive retirement benefits under the plan in a special payment form, unless you choose a different payment form and your spouseagrees to that choice. This special payment form is often called a "qualified joint and survivor annuity" or "QJSA" payment. The QJSA payment gives your spouse amonthly retirement payment for the rest of his or her life. The benefit paid after a spouse dies is often called an “annuity”, "survivor annuity" or a "survivor benefit."The Plan Administrator shall, no less than 30 days and no more than 90 days prior to the Annuity Starting Date, provide each Participant a written explanation of (1)the terms and conditions of a Qualified Joint and Survivor Annuity; (2) the Participant's right to make an election to waive the Qualified Joint and Survivor Annuityform of benefit and the effect of such election; (3) the rights of a Participant's spouse; and (4) the right to make a revocation of a previous election to waive theQualified Joint and Survivor Annuity, and the effect of such revocation. Your Plan Administrator must provide you with information regarding your options and shouldcoordinate payments with an annuity provider, if applicable.APPLICABILITY OF ANNUITY REQUIREMENTS (to be completed by the Plan Administrator)According to the records of the Plan, the joint and survivor annuity and preretirement survivor annuity provisions:Do not apply to the Participant.Do apply to the Participant. (The Plan Administrator must provide the Participant all pertinent information concerning Joint and Survivor Annuity options.)SPOUSAL CONSENT (for Plans subject to annuity requirements)I, the undersigned spouse of the Participant, have read the Participant’s Request for a Qualified Plan Distribution, and hereby consent to the distribution of myspouse's benefits under the Plan as requested. I have signed this consent freely and voluntarily.Signature of Spouse: Date:BEFORE ME, the undersigned Notary Public, personally appearedDateand executed the above Spousal Consent.IN WITNESS WHEREOF, I have signed my name and affixed my official seal of office onSignature of Notary:Notary Public - State ofMy commission expiresQP 2015QP Distribution FormPage of 1 of 3
DISTRIBUTION REASONIn accordance with the terms of the Plan, I hereby request that a distribution from such Plan be made in the following manner. I understand that the PlanAdministrator will make the final decision as to whether a distribution is appropriate under the terms of the Plan and as to the timing and the form of distribution.Note: There is a mandatory 20% Federal tax withholding from all qualified plan distributions, except for direct rollovers, asset transfers, required minimumdistributions, and others as described in the Rollover Explanation For Qualified Plans and 403(b) Plans - Special Tax Notice Regarding Plan Payments.I direct the Depository custodian to make a distribution from the referenced custodial account for the following reason (check one):1.Early (premature) Distribution, no known exception applies - This also applies if you are separated from service and are under age 55. If separated fromservice and you are requesting a direct rollover to an IRA, 403(b) or qualified plan, check this box . You must also complete and attach Form B - QualifiedPlan Direct Rollover/Affirmative Election Form.2.Early (premature) Distribution, exception applies - This reason applies to separation from service after age 55 (including retirement) or an IRS Levy. Ifseparated from service or retired and you are requesting a direct rollover to an IRA, 403(b) or qualified plan, check this box . You must also complete andattach Form B - Qualified Plan Direct Rollover/Affirmative Election Form.3.Normal Distribution - You are the participant who is age 59½ or older and no other reason applies. If you are requesting a direct rollover to an IRA, 403(b) orqualified plan, check this box . You must also complete and attach Form B - Qualified Plan Direct Rollover/Affirmative Election Form.4.Substantially Equal Periodic Payments (after separation of service) - You are certifying that you meet the requirements within the meaning of Section 72(t) ofthe Internal Revenue Code. Please complete option #4 in the section titled Distribution Request.5.Permanent Disability - You are disabled within the meaning of Section 72(m)(7) of the Internal Revenue Code. (For purposes of Section 72(m)(7), an individualshall be considered to be disabled if they are unable to engage in any substantial gainful activity by reason of any medically determinable physical or mentalimpairment which can be expected to result in death or to be of long-continued and indefinite duration.) If you are requesting a direct rollover to an IRA,403(b) or qualified plan, check this box . You must also complete and attach Form B - Qualified Plan Direct Rollover/Affirmative Election Form.6.Participant’s Death - If you are a beneficiary, please contact Shareholder Services for additional requirements. If you are requesting a direct rollover, checkthis box . You must also complete and attach Form B - Qualified Plan Direct Rollover/Affirmative Election Form.7.Prohibited Transaction as defined by Internal Revenue Code 4975.8.Corrective Distributions of Excess Deferrals, Excess Contributions and/or Excess Aggregate Contributions under sections 401(k) and 401(m).Date of Excess Contribution Deposit:9.Plan Termination - Termination Date:10. In-Service Distribution (Profit-Sharing Plans only) - Indicate Type:Hardship24 mo. rule60 mo. ruleother:11. Distribution pursuant to a Qualified Domestic Relations Order (QDRO) - You must include a certified copy of the QDRO. If the proceeds are to be directlyrolled into an IRA, 403(b) or qualified plan, you must also complete and attach Form B - Qualified Plan Direct Rollover/Affirmative Election Form.12. Qualified Rollover Contribution - (Conversion) - You are electing to convert the proceeds of your employer’s qualified plan to a Roth IRA. You must alsocomplete and attach Form B - Qualified Plan Direct Rollover/Affirmative Election Form.Important: For non-reportable trustee to trustee transfers please complete the appropriate receiving custodian’s transfer form. All required documentation must bereceived in good order before the distribution request will be honored. All legal documents must be certified and a Medallion Signature Guarantee may be required.PLAN ADMINISTRATOR AUTHORIZATION (REQUIRED)Plan Administrator’s Signature:Date:Plan Administrator’s Printed Name:Telephone Number:DISTRIBUTION REQUESTI request that the proceeds from my custodial account be paid as follows: (Amount and Frequency)1. Entire Account Balance - in a single payment of the available balance in my account.2. Partial Distribution Amount in a single payment from Fund(s):3. Periodic Distribution Amount from Fund(s):a)Automatic withdrawals in a series ofmonthlyquarterlysemi-annualannual installmentsbeginning onb)Automatic withdrawals in a series ofmonthlyquarterlysemi-annualannual installmentsbeginning on andcontinuing over a fixed period ofmonthsyears4. Substantially Equal Periodic Payments within the meaning of Section 72(t) of the Internal Revenue Code distributed proportionally across all investments.Distribute in a series ofmonthlyquarterlysemi-annualannual installments beginning onFixed Amount or,Calculate under the RMD method using the following table:Uniform Lifetime TableSingle Life TableJoint and Last Survivor Table**Beneficiary’s Name: Date of Birth:QP 2015QP Distribution FormPage of 2 of 3
METHOD OF PAYMENTBased on your selected distribution method, a Medallion Signature Guarantee Stamp may be required. Please refer to your prospectus or call us for specificrequirements.Process a Direct Rollover – I have completed, attached and signed Form B - Qualified Plan Direct Rollover/Affirmative Election Form providing paymentinstructions.Mail check to my address of record currently on file.Purchase into my non-retirement account.Application attached with investment instructions(or)Existing Account Numberinvesting in the following Fund(s):Transfer funds electronically via ACH.Existing instructions on fileNew - Requires Medallion Signature Guarantee Stamp (attach a voided check).Name of Financial Institution:Address:Bank Routing Number: Bank Account Number:The receiving bank accountmust include your name in theaccount registration.Mail check to the bank address above for deposit. (Not for Direct Rollovers or Transfers.)Note: If a payment method is not selected, the proceeds will be issued as a check payable to you and mailed to your address of record.FEDERAL WITHHOLDINGSection I - Voluntary Withholding - This section applies if the distribution is not an "eligible rollover distribution" as described in §402(c) of the Internal RevenueCode. Eligibility is described in the Rollover Explanation For Qualified Plans and 403(b) Plans - Special Tax Notice Regarding Plan Payments. (Check one of thefollowing boxes.)I elect TO NOT have federal income tax withheld from my payment(s). This option is only available for accounts registered with an address in the United States.I elect TO have % federal income tax withheld from my payments.NOTE: Even if you elect not to have federal income tax withheld, you are liable for payment of federal income tax on the taxable portion of your distribution orwithdrawal. You may also be subject to tax penalties under the estimated tax payment rules if your payments of estimated tax and withholding, if any, are notadequate.Section II - Mandatory 20% Withholding - This section applies if the distribution is an "eligible rollover distribution" as described in §402(c) of the Internal RevenueCode and you do not elect to directly roll the monies into another qualified plan, 403(b) or individual retirement account. I understand that I will receive only 80% ofthe payment since the Depository custodian is required to withhold 20% of the distribution and send it to the IRS as federal income tax withholding to be creditedagainst my taxes.STATE WITHHOLDINGYour state of residence will determine your state income tax withholding requirements, if any. Those states with mandatory withholding will require state income taxto be withheld from payments if federal income taxes are withheld. Voluntary states let individuals determine whether they want state taxes withheld. Some stateshave no income tax on retirement payments. Please consult with a tax advisor or your state's tax authority for additional information on your state requirements.I elect TO NOT have state income tax withheld from my retirement account distributions (only for residents of states that do not require mandatory state taxwithholding).I elect TO have the following dollar amount or percentage from my retirement account distribution withheld for state income taxes (for residents of states thatallow voluntary state tax withholding). or %PARTICIPANT CERTIFICATIONI certify that I am the proper party authorized to make these elections and that all information provided is true and accurate. I further certify that no tax or legaladvice has been given to me by the Depository custodian, the Sponsor, or any agent of either of them, and that all decisions regarding the elections made on thisform are my own. The Depository custodian is hereby authorized and directed to distribute funds from my account in the manner requested. The Depositorycustodian may conclusively rely on this certification and authorization without further investigation or inquiry. I expressly assume responsibility for any adverseconsequences which may arise from the election(s) and agree that the Depository custodian, the Sponsor, and their agents shall in no way be responsible, and shallbe indemnified and held harmless, for any tax, legal or other consequences of the election(s) made on this form. I have received, read, understand and agree to belegally bound by the terms of this form. By completing this form, I am affirmatively electing to waive the 30 day notification period as described in the RolloverExplanation For Qualified Plans and 403(b) Plans - Special Tax Notice Regarding Plan Payments.Signature:Date:*Medallion Signature Guarantee Stamp and Signature (If required by your currentcustodian or transfer agent): An eligible guarantor is a domestic bank or trustcompany, securities broker/dealer, clearing agency or savings association thatparticipates in a medallion program recognized by the Securities Transfer AgentsAssociation. The three recognized medallion programs are the Securities TransferAgents Medallion Program (known as STAMP), Stock Exchanges Medallion Program(SEMP), and the Medallion Signature Program (MSP). A notarization from a notarypublic is NOT an acceptable substitute for a signature guarantee.QP 2015QP Distribution Form*Medallion Signature Guarantee StampPage of 3 of 3
Voya Investment ManagementP.O. Box 9772Providence, RI 02940-97721-800-992-0180FORM B - QUALIFIED PLAN DIRECT ROLLOVER / AFFIRMATIVE ELECTION FORMYou must complete FORM A - PARTICIPANT'S REQUEST FOR A QUALIFIED PLAN DISTRIBUTION and attach it to this form. Failure to do so will cause yourrequest to be rejected.PARTICIPANT INFORMATIONParticipant Name:Account Number:Surviving Spouse, Beneficiary, Former Spouse or Alternate Payee Name:AFFIRMATIVE ELECTION – for Direct Rollover1)Depending upon your relationship to the participant, complete either a, b or c below.a) DIRECT ROLLOVER by:DIRECT ROLLOVER to:Plan ParticipantSurviving SpouseQualified Plan403(b) PlanRoth IRA as a Qualified Rollover Contribution (conversion)b) DIRECT ROLLOVER by:Traditional IRADIRECT ROLLOVER to:Non-Spouse BeneficiaryBeneficiary / Inherited Traditional IRABeneficiary / Inherited Roth IRA as a Qualified Rollover Contribution (conversion)c) DIRECT ROLLOVER by:DIRECT ROLLOVER to:Former Spouse or Alternate Payee under aQualified Domestic Relations Order (QDRO)2)This election shall apply to (check one):a)3)Qualified Plan403(b) PlanTraditional IRARoth IRA as a Qualified Rollover Contribution (conversion)The entire account balance(or)b) as listed in Form A under the section titled Distribution Request.I hereby elect to have my benefit under the Qualified Plan custodial account paid in a DIRECT ROLLOVER to (please print):Successor Custodian:For Benefit of: (or)(Participant, Surviving Spouse, Former Spouse or Alternate Payee)For a Non-Spouse Beneficiary/Inherited IRA, For Benefit of:(Non-Spouse Beneficiary)(Qualified Plan Participant’s Name)Account Number*:Successor Custodian Address:Contact Name:Telephone Number:*Note: You must contact the successor custodian and provide them direction as to how you want the proceeds invested.CERTIFICATION SIGNATUREI certify I have received and read the Rollover Explanation For Qualified Plans and 403(b) Plans - Special Tax Notice Regarding Plan Payments and understand that Ihave at least 30 days to choose between a direct rollover or payment. I authorize and direct the Depository custodian to facilitate a direct rollover as indicated above.By completing this form, I am affirmatively electing to waive the 30 day notification period as described in the Rollover Explanation For Qualified Plans and 403(b)Plans - Special Tax Notice Regarding Plan Payments.Signature:Date:(Participant, Surviving Spouse, Beneficiary, Former Spouse or Alternate Payee)QP 2015QP Direct Rollover NoticePage 1 of 1
Voya Investment ManagementP.O. Box 9772Providence, RI 02940-97721-800-992-0180FORM C - QUALIFIED PLAN REQUIRED MINIMUM DISTRIBUTION ELECTION FORMNote: Failure to withdraw your required minimum distribution amount by the applicable deadline could result in a 50% penalty tax. The penalty taxwould be assessed on the difference between the amount that you were required to take and the amount that was actually distributed, if any.PARTICIPANT INFORMATIONParticipant Name:Social Security Number:Date of Birth:Telephone
The Plan Administrator shall, no less than 30 days and no more than 90 days prior to the Annuity Starting Date, provide each Participant a written explanation of (1) the terms and conditions of a Qualified Joint an
