HR Retirement Plan Transition Form

HR Retirement Plan Transition Form

Personal Information

Position Information

Employment History (Most Recent)

Education

References (Professional)

Current Retirement Plan Details

Vesting Status: Fully vested Partially vested Not vested

Requested Transition Instruction

Please indicate the requested disposition of your vested account (select one or more as applicable):

Rollover to new employer's plan — New Plan Name:

Rollover to IRA — IRA Custodian:

Cash distribution (I understand applicable taxes and penalties may apply)

Leave funds in current plan

Tax Withholding & Withholding Elections

Federal income tax withholding on distributions (if applicable): Apply mandatory withholding Request no withholding (if permitted)

Beneficiary Designation

Primary Beneficiary (allocate 100% among primary beneficiaries)

Contingent Beneficiary (if no primary survives)

Legal Disclosures & Authorizations

At-Will Employment: I acknowledge that my employment status with the employer is at-will and that nothing in this form alters my at-will employment status unless a separate written agreement expressly provides otherwise and is signed by an authorized representative.

Equal Opportunity: The employer is an equal opportunity organization. Selection for plan participation, rollover processing, or distribution is administered consistent with applicable nondiscrimination and equal opportunity rules.

Authorization to Contact Previous Employers and Conduct Background Checks: I authorize the employer and its agents to contact prior employers, custodians, and plan administrators and to obtain records necessary to effectuate this transition, including but not limited to employment, compensation, and benefit plan records. I also consent to any background checks necessary to validate plan eligibility and to comply with plan or legal requirements.

Certification and Authorization

I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that the requested transfer or distribution may have tax consequences and that I am responsible for consulting a tax advisor as needed. I authorize the plan administrator, payroll, and custodial entities to take such actions as are necessary to implement this election, including release and transfer of funds, processing of tax withholdings, and communication with designated custodians. I release the employer and plan fiduciaries from liability for actions taken in good faith pursuant to this authorization.

I further understand that incomplete or inaccurate information may delay processing. I authorize the release of information to the receiving plan or custodian as required to complete a rollover or transfer.

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