Fill and Sign the Medical Certificate Mauritius Form

ROLL #:_______________ Oneida Tribe of Indians of Wisconsin TRUST DEPARTMENT P.O. BOX 365, ONEIDA, WI 54155 PHONE: (920) 490- 3935 1-800-869-2214 MINOR TRUST PAYMENT/DEFERRAL OPTION FORM Section 1: Member Information Roll Number: Birth Date: Telephone:( ) ‐ Last First Middle ❒ TAX Member Name: Maiden Check Address: Street or PO Box Apt # City State Zip ❒ DEFERRED SIGNING HERE AUTHORIZES FEDERAL INCOME TAX WITHHOLDING Signature: Date: Section 3: Signature and Notarization (choose ONE option) I wish to defer ˆ 25% ˆ 50% ˆ 75% ˆ 100% ❒ INCOMP ˆ I wish to claim my entire trust account (if chosen, then skip Section 4 & Section 5). of my trust account I understand that my elections on this Form may override the regular Trust Distribution rules and that my elections are subject to all terms and restrictions of the Trust. I have read and understand the Summary of Deferral Rules. I, the undersigned, under Penalty of Perjury, depose and say that all of the information in section one is true and correct. If member is under 18, a parent or guardian signature is required Signature: Date: CERTIFICATE OF NOTARY PUBLIC Subscribed and sworn to before me this (SEAL/STAMP) of day , . Notary Signature My commission expires . Page 1 of 2 Office Use Only: I hereby request the Oneida Tribe of Indians of Wisconsin to withhold 20% of my Minor Trust Payment for my Federal Income Tax Account. This withholding request shall remain in effect until a new payment form is submitted to the Oneida Trust Department. I hereby absolve the Oneida Tribe of Indians of Wisconsin of any liability for honoring this federal income tax withholding request. ❒ DIPLOMA Section 2: Voluntary Federal Income Tax Withholding Request Section 4: Contingent Beneficiary(s) As a beneficiary of a trust and the fact that you will have reached or are of the age of majority, you will need to determine a contingent beneficiary should you pass away while funds remain in the trust. % Full Name Social Security # Relationship Address Birth Date Roll # In the event that any of the above Contingent Beneficiaries should die before me, his/her share shall be divided equally among the remaining Contingent Beneficiaries. Section 5: Summary of Deferral Rules ¾ I understand that if I die before my benefits are paid, my benefits will be paid to my estate or to my Contingent Beneficiaries (if selected). Prior to age 18, my parents must execute a Contingent Beneficiary selection. ¾ I understand that I may change my Contingent Beneficiary at any time (parent consent required if under age 18). A change must be notarized and accepted by the Trust Department prior to becoming effective. In the absence of a valid Contingent Beneficiary designation, Trust assets will be paid under the Tribe’s probate laws. ¾ I understand that my Deferral Agreement is irrevocable, except in the event of an Unforeseeable Emergency as provided in the Trust Agreement. ¾ I understand that this Deferral Agreement and Payment Election Form are subject to all terms and conditions of the Trust Agreement. ¾ I understand that I may not change my date of payment to an earlier date, except in the event of an Unforeseeable Emergency. ¾ I understand that Optional Minor Deferral Elections are limited to enrolled members, and that the Trustee, in its sole discretion, may cancel an election or accelerate any distribution upon dis‐enrollment. ¾ I understand that the Trustee has discretion to place additional restrictions on my elections as necessary to avoid premature taxation through IRS doctrines of constructive Receipt and economic benefit. ¾ If I want to make a change to this Form based on an Unforeseeable Emergency, I understand that I will need to apply to the Trust Department and provide documentation in support of my emergency. ¾ I understand that my elections and any permitted changes are subject to restrictions and rules designed to comply with the Internal Revenue Code and prevent premature taxation. I UNDERSTAND THAT THIS FORM WILL NOT BE VALID UNLESS IT IS SIGNED AND ACCEPTED BY THE TRUSTEE NO LATER THAN 3 MONTHS PRIOR TO MY ELIGIBILITY BIRTHDATE SET OUT IN ARTICLE III‐B(1)(I) AND (II) OF THE TRUST AGREEMENT, WHICHEVER IS APPLICABLE. Page 2 of 2 FY‐2011 MINOR TRUST ACCOUNT INSTRUCTIONS PLEASE READ: These instructions provide you with options to claim all or a portion of your trust account monies. ™ To return your Completed/Notarized Minor Trust Account Payment/Deferral Form to: FOR UNITED STATES POSTAL SERVICE ONEIDA TRUST DEPARTMENT PO BOX 365 ONEIDA WI 54155‐0365 FOR COURIER DELIVERY ONEIDA MAIL CENTER 2701 W MASON ST GREEN BAY, WI 54303 NO MAIL RECEPTACLE – Do Not use if mailing from the United States Post Office. Address for Courier Delivery only i.e. Fed Ex, UPS ™ Submit proof of graduation. ¾ Original High School Diploma, GED, or HSED ¾ Notarized High School Diploma, GED or HSED ¾ Letter from the school/agency you graduated from. ˜ The letter must indicate that you graduated ˜ The letter must be printed on school/agency letterhead ˜ The letter must be stamped with the school/agency seal ˜ The letter must be mailed directly to the Trust Department from the school in a sealed envelope. ™ FORM DEADLINE IS: Close of Business on Monday, September 1, 2011. ™ To make changes to your minor check address or voluntary federal income tax withholding, you must submit a new notarized minor trust account payment form no later than September 1, 2011. ™ Forms are UNACCEPTABLE if any of the following apply: ¾ Check address is incomplete/blank ¾ Pencil or white out that alters the check address ¾ No authorized signature in section 3 ¾ Altered information (crossing/scribbling out) ¾ Notary section is incomplete/blank ¾ Photocopied, Faxed, E‐mailed (scanned) ™ For persons assigned as a Power of Attorney (POA)/Guardian/Conservatorship, acceptable documentation must be on file with the Enrollment Department. Members identified as Incompetent, please note: these monies will be placed in an Adult Trust Account and co‐managed by both the Enrollment and Trust Departments. If you have any questions, please contact either department for more information. Enrollment Department: (920) 869‐6200 Trust Department: (920) 490‐3935 ™ Mandatory Federal Income Tax Withholding is required on; ¾ Payments as indicated on page 67 of IRS Publication 15‐A (For 2011, payment amounts totaling over $9,350.00 are subject to this withholding) ¾ A mandatory back up withholding tax of 28% will be applied to Payments for those who have not provided their Social Security Number or Non‐citizenry information. ™ For forms received with applicable documentation by the deadline date: ¾ Checks will be mailed the 3rd week in October 2011. Please allow time for delivery. ¾ A separate 1099‐Misc tax form will be mailed no later than January 31, 2012. ™ NOTE: You are eligible to claim your Adult Payment, whether or not you graduated. Please complete, notarize and return your FY‐2011 Membership Payment form on or before September 1, 2011 to the Oneida Enrollment Department. This payment will not be added to your Minor Trust account and will expire if it is not claimed within 1 year. Please contact the Trust Department: (920) 490‐3935 with additional questions. Who Should Complete This Form: ‐ If your date of birth is on or after 9/2/1992 and on or before 9/1/1993. ‐ If your date of birth is prior to 9/2/1992 and you deferred part of your payment last year and would like to make another one‐ year deferral or claim the balance of your account. ‐ If your date of birth is prior to 9/2/1992 and would like to make a deferral or claim your payment. How to Complete This Form: Section 1: Member Information ‐ Complete all blanks in this section. ‐ If you do not know your “Roll Number:”, that is okay. o Include your “Birth Date:” and your form will be accepted. Section 2: Voluntary Federal Income Tax Withholding Request ‐ If you sign this section, 20% of your payment will be withheld for your Federal Tax Account. This withholding will be shown on a 1099‐misc tax form (mailed at the beginning of February 2012). ‐ You can skip this section, it is not required. ‐ If you do not know if you should sign this section, you should contact a tax professional. Trust and Enrollment Department Staff cannot help you make this decision. Section 3: Signature and Notarization ‐ Check only ONE (1) box. o If you claim your entire account, you do not need to complete the back of the form. ƒ You must get the form notarized. o If you choose to defer, you need to complete the back of the form. ƒ For questions on deferral rules/processes, please contact the Trust Department. ƒ If you are 18, you must get the form notarized. ƒ If you are not yet 18, your parent or guardian must get the form notarized. ‐ Get form Notarized. o Go to a Notary Public with a picture ID. o Sign and date when instructed by the Notary. Section 4: Contingent Beneficiary(s) ‐ If you chose to claim your entire account in Section 3, skip this section. ‐ If you chose to defer in Section 3, you must complete this section. o For questions on the deferral process, please contact the Trust Dept. Section 5: Summary of Deferral Rules ‐ If you chose to claim your entire account in Section 3, skip this section. ‐ If you chose to defer in Section 3, you must read and understand this section. o For questions on the deferral process, please contact the Trust Dept.