Employee Pension Termination

EMPLOYEE PENSION TERMINATION

Employee Name:   Employee ID:

Employer Name:   Plan Name:   Plan Number:

Effective Termination Date:

Personal Information

Position Information

Hire Date:   Termination Date:

Employee Contribution Rate:   Vested Percentage:   Accrued Benefit Amount: $

Employment History (Most Recent)

Education

References

Legal Notices and Disclosures

At-Will Employment: Nothing in this form alters the at-will employment relationship between the employee and employer unless expressly stated in a separate written agreement signed by both parties.

Equal Employment Opportunity: The employer maintains policies consistent with equal opportunity and non-discrimination in employment and benefits administration.

Pension Termination Notice: By signing this form the employee requests termination of participation in the pension plan identified above effective as of the Effective Termination Date. The employee acknowledges that termination may have immediate or future consequences including, but not limited to, loss of contribution matching, forfeiture of unvested benefits, tax consequences associated with distributions, and deadlines for rollovers or claims. Distribution elections made on this form will be processed in accordance with plan documents and applicable law.

Distribution Election (Select one)

 Lump-sum distribution (payable to employee, subject to applicable withholding and taxes)

 Direct rollover to another qualified retirement plan or IRA   Institution name:   Account #:

 Deferred annuity or leave benefit in plan (if permitted by plan terms)

Beneficiary Confirmation

Authorization and Certification

 I authorize the employer and plan administrator to contact my previous employers and benefit providers to verify employment, service, compensation, and pension records as necessary to effectuate termination and distribution processing.

 I authorize the employer and plan administrator to obtain background or verification information relevant to plan administration if required.

I certify under penalty of perjury that the information provided in this form is true, complete, and accurate to the best of my knowledge. I acknowledge receipt of any notices required by the plan, and I understand that processing of my election is subject to plan provisions, vesting rules, and applicable law. I further agree to indemnify and hold harmless the employer and plan administrator for reliance on the information and elections provided herein, to the extent permitted by law.

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