Employee Retirement Instructions

EMPLOYEE RETIREMENT INSTRUCTIONS

Personal Information

Employee Name:

Position & Employment Details

Current Job Title:

Intended Retirement Effective Date: Month Day Year

Retirement Benefit Elections

Select elections for company-administered retirement benefits (check applicable):

Lump-sum distribution of defined benefit plan (pension) - I request payout as a lump-sum
Annuity (periodic payments) - I elect the standard single-life annuity option
Direct rollover of 401(k) to an outside qualified plan or IRA
Direct distribution to me (subject to tax withholding as elected below)

Tax Withholding & Payment Instructions

For taxable distributions, withhold federal and state taxes as follows:

Health Insurance & Benefits Continuation

I request the following post-employment coverage actions (check all that apply):
Election of continuation coverage under applicable continuation provisions
Enrollment in employer-sponsored retiree health plan (if eligible)
Decline continuation or retiree coverage

Final Pay, Accrued Leave & Company Property

Final pay and accrued leave payout instructions (select one):
Direct deposit to existing payroll account on final paycheck
Physical check mailed to home address above

Company property to be returned prior to effective date (check items possessed):
Laptop/computer
Mobile phone
ID/badge/keys
Other (describe below)

Beneficiary & Emergency Contact

Employment History (Most recent two employers)

Start Month Start Year End Month End Year

Start Month Start Year End Month End Year

Education

Graduation Month Graduation Year

References

Please provide three professional references.

Legal Disclosures & Authorizations

At-Will Employment: I acknowledge that my employment status prior to retirement was governed by at-will employment policies where applicable, and that these instructions do not alter the at-will nature of employment unless set forth in a signed written agreement.

Equal Opportunity: The employer maintains an equal employment opportunity policy. Retirement and post-employment benefits will be administered in accordance with applicable nondiscrimination laws and employer policy.

Authorization to Obtain Records: I authorize the employer and its designated agents to contact prior employers, plan administrators, and benefit providers as reasonably necessary to verify employment, benefits eligibility, service credit, and compensation history for the purpose of calculating retirement benefits and final pay.

Background/Benefits Verification: I consent to any background checks or benefits verification necessary to effectuate retirement benefits and final compensation, subject to applicable law. I understand that providing false information may be cause for denial of benefits or legal action.

Employee Certification

I certify that the information and elections contained in this Employee Retirement Instructions form are true, complete, and correctly reflect my intentions. I understand that some elections are subject to plan documents, eligibility, and final administrative determination. I release the employer from liability for actions taken in good faith in reliance on these instructions.

Initial to confirm certification:

Representative / Power of Attorney (if applicable)

If a representative will act on my behalf for retirement matters, provide name and attach any required power of attorney documentation to HR.

Special Instructions or Comments

Authorization to Process

By signing below I authorize the employer to implement the elections and administrative actions set forth in this document, including processing benefit distributions, enrolling or declining post-employment benefits, and issuing final compensation consistent with company policy and plan documents.

I further confirm that I have read and understand the statements above and that I have the authority to make the elections indicated.

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