State of Arizona Deferred Compensation Payout Request Form

State of Arizona
Deferred Compensation
Payout Request Form
Personal Information
Plan Type: c 457(b) c 401(a) c 403(b) c All
Participant Name:
Participant SSN:
Mailing Address:
City, State* & Zip Code:
Date of Birth:
Phone Number:
Email Address:
Date of Separation:
How would you like to be contacted if additional information is required? c Telephone c Email
*NRS will use the state provided in your mailing address as your state of residency for tax purposes, unless instructed otherwise.
Action Requested
c Initiate payout
c Stop current payments (Systematic Withdrawal Options only.)
c Change/Restart (Wish to change/restart option or distribution amount.)
Distribution Reason (Check the option that applies)
Note: See Important Information section for more detail
c Severance of Employment
c Retirement
c Disability
c Required Minimum Distribution
c In-Service
Distribution Source
Do You Prefer Your Distribution to Come From:
c Salary Pre-Tax
c Rollover
c Roth
c All
All funds will be withdrawn pro-rata across all funding options within the selected account.
One Time Payment** (Select One Option)
c Entire account balance
c Partial amount of $ Minimum of $25.00* (Amount including tax withholding)
*The terms of the Plan Document govern the minimum amount allowed for partial one-time payments. Some plans require a $1,000
minimum for a partial one-time payment.
** Skip to “Payment Method” section on page 4, if you select this option
Payout Options (Select One Option)
Systematic Payment Option
Frequency: c Monthly c Quarterly c Semi-Annually c Annually
If no payment frequency is selected, payment will be set-up for the default option of monthly.
Systematic Start Date: If start date is not provided, the payment start date will be the date your request is processed. The receipt date of your
payment is dependent upon the payment method you select.
c Fixed Dollar Payment: Specified amount (minimum of $25.00) paid to you until your account balance is zero (final
payment may be less). The number of payments you receive will vary depending on the earnings (gains/losses) your
account experiences.
Payment Amount: $ (Amount including tax withholding)
DC-2474 (8/2016)
For help, please call 800-796-9753
Payout Options (Select One Option) (continued)
c Fixed Period Payment: Account balance paid to you for the number of years selected. The actual dollar amount
will vary depending on the earnings (gains/losses) your account experiences, and the duration requested. You must
choose a calculation method for your payment. If no calculation method is selected, payments will default to the
standard method with annual calculations.
Number of Years:______________ (1-30 years)
Please select a calculation method:
Standard: c Annually (Default Option) OR c Per Pay Period
Assumed Growth Rate: c Cost of Living Adjustment c 3% c 4% c 5% c 6% c 7% c 8% c 9%
c Life Expectancy and Lifetime Payment (Please select a calculation method)
Life Expectancy / Joint Life Expectancy*: c Life Expectancy OR c Joint Life Expectancy*
Lifetime / Joint Lifetime*: c Lifetime OR c Joint Lifetime*
Beneficiary Date of Birth (MM/DD/YYYY): *Joint Life and Joint Lifetime calculations will be based on the joint life expectancy of you and your primary beneficiary at the time of
Purchased Annuities
Nationwide Purchased Annuities (Please select a calculation method)(Your election of a purchased annuity is irrevocable.)
c Single Life Annuity (No Beneficiary)*: This option provides equal payments over your lifetime. At the participant’s
death, payments will stop. There is no named beneficiary. Attach proof of date of birth.
c Fixed c Variable
c Life Income with Payments Certain*: This option provides payments for your lifetime. If you die before the selected
number of guaranteed payments has been made, payments will continue to your named beneficiaries until the total
number of guaranteed payments has been made to you and your beneficiary.
c Fixed — c 5 years c 10 years c 15 years c 20 years c 25 years c 30 years
c Variable c Joint and Survivor*: This option provides payments for you and your survivor for your lifetimes. Upon your death,
payments will continue to survivor, if he or she is living.
c Fixed — c 50% c 66⅔% c 75% c 100% |
c Variable
Survivor: Mailing Address: City: State: ZIP: SSN: Phone Number: Date of Birth: *Attach proof of date of birth for Life Annuity, Life Income and Joint & Survivor
c Fixed Designated Period: This option provides for payments for the number of years chosen. You may select any
whole number of years between 3 and 20, inclusive. If you should die before the end of the period, payments will
continue to the beneficiary.
Number of Years:______________ (3-20)
c Designated Amount: This option provides for payments of a specified dollar amount, not less than $25.00. The length
of the payout is determined by the account value and a set purchase rate.
Payment Amount: $ .
DC-2474 (8/2016)
For help, please call 800-796-9753
Payout Options (continued)
Prudential Purchased Annuities (Please select a calculation method)(To be paid monthly)
FF Life Payment Certain Annuity: Monthly payments guaranteed for my lifetime or for years (choose 3 to 25 years) if longer.
FF Joint and Survivor–Life Contingent Annuity: Monthly payments guaranteed for my lifetime and that of my beneficiary
following my death or for a period of beneficiary named below will be equal to payment I am receiving. (Attach proof of birth).
years (choose 3 to 25 years). Payments made to my
(choose 33 1/3%, 50%, 66 2/3%, or 100%) of the monthly
Survivor: Mailing Address: City: State: ZIP: SSN: Phone Number: Date of Birth: FF Payment Certain Annuity: Monthly payments guaranteed for ___________years (choose 3 to 25 years).
Universal Life Policy: If you wish to use the Universal Life Policy, please call a Retirement Specialist at 800-796-9753.
Rollover Distributions: If you wish to rollover your funds, please call a Retirement Specialist at 888-224-1011..
Important Information
Money Sources
Funds will be withdrawn equally across all money sources and investment options for each requested distribution unless
instructed otherwise. Distributions from rollover and Roth sources may be subject to an additional excise tax.
Distribution Reasons
The terms of the Plan Document govern the availability of distribution types. All distribution types offered on this form
may not be permitted under the terms of your Plan.
Self-Directed Brokerage Account
If you have money in the Self-directed Brokerage account and the requested amount exceeds your core account balance,
you will need to transfer funds back to the core account before your request can be processed. If you select a systematic
payment, you will need to maintain a sufficient balance in your core account to cover your elected amount.
If you would like to confirm or update your beneficiary information, please visit our website at or contact
our customer service center at 800-796-9753.
DC-2474 (8/2016)
For help, please call 800-796-9753
Payment Method
Select One:
FF ACH Instructions on File – Send funds to my bank account that Nationwide has on file.
FF Send check by first class mail to my address of record. Allow 5 to 10 business days from process date for delivery.
(Default option, if no other option is selected)
FFI authorize NRS to send my payout check to me via overnight check to address of record for a fee of $25 (We will deduct
the $25 from your account. Please also note, we can’t offer overnight delivery to a PO Box and Saturday delivery may
not be available in your area)ACH Instructions on File – Send funds to my bank account that NRS has on file.
FF Direct Deposit ACH (complete information below)
Financial Institution Information:
John Doe
123 Main Street Ph. (614) 555-1212
Hometown, OH 45678
Bank Name
ABA (routing) Number
Money Bank, Inc.
321 Main Street
Hometown, OH 45678
Account Number
Account Type: c Checking c Savings
NOTE: If left blank, we will default to checking.
| 123456789 |
9-digit ABA routing number
000012345678 ||•
Checking Account Number
Check Number
NOTE: Direct Deposit is only offered through members of the Automatic Clearing House (ACH). We cannot accept a
deposit slip or starter check for banking numbers.
Is this account associated with a brokerage firm or other investment firm?
c Yes
c No
If yes, have you confirmed that the ABA and account numbers are correct?
c Yes
c No
I hereby authorize Nationwide to initiate automatic deposits to my account at the financial institution named above. In
the event an error is made, I authorize Nationwide to make a corrective reversal from this account. Further, I agree not to
hold Nationwide responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or
by my financial institution or due to an error on the part of my financial institution in depositing funds to my account. This
agreement will remain in effect until Nationwide receives a written notice of cancellation from me or my financial institution,
or until I submit a new direct deposit authorization form to Nationwide. In the event this direct deposit authorization form
is incomplete or contains incorrect information, I understand a check will be issued to my address of record.
Tax Withholding
Federal Tax: NRS will withhold federal tax as required by the IRS from the payment you choose. See the Special Tax
Notice Regarding Plan Payments for specific tax information and IRS required withholding before completing. You may
elect below to have no withholding from your required minimum distribution or systematic payments that last 10 years
or more. The standard federal tax withholding rate is 20%. Please skip this section unless you would like a different
amount or percentage to be withheld.
FFI would like additional federal tax withheld above the IRS mandatory 20% in the amount of:
$ OR %
FFI have a required minimum distribution or systematic payment lasting 10 years or more and would like federal tax withheld
based on my election on Form W-4P
FFDo Not withhold federal tax in accordance with my election of Form W-4P from my required minimum distribution or
systematic payment lasting 10 years or more.
State Tax: State taxes will be automatically withheld if you are a resident in a state that mandates state income tax
withholding. If you would like to adjust your state taxes, please complete and attach a state tax withholding form. These
forms can be obtained from the State web site, NRS does not supply these forms.
DC-2474 (8/2016)
For help, please call 800-796-9753
Under penalty of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued
to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report
all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding,and
3. I am a U.S. citizen or other U.S. person.
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
You must cross out item (2) if you have been notified by the IRS that you are currently subject to backup withholding
because of failure to report interest or dividends on your tax return.
By signing this form, If I have an outstanding loan and I am requesting a total distribution of my account, I understand the
outstanding loan balance will be part of this total distribution and may be taxable income reported to the IRS on form
1099-R. Any pending loan payments may delay the processing of this withdrawal.
By signing below, I hereby acknowledge the following information: 1. Rollover contributions to governmental 457(b) plans
that originated from qualified plans, IRAs and 403(b) plans are subject to the early distribution tax that applies to 401(a)
/ 401(k) plans unless an exception applicable to 401(a) / 401(k) plans applies. 2. Rollover contributions are subject to the
Required Minimum Distribution (RMD) rules of the plan they are rolled into, not the plan or IRA from which they came.
Federal income tax will be withheld from your payments as required by the Internal Revenue Code. If you select a lump
sum or systematic withdrawal lasting less than 10 years 20% of the taxable portion of the distribution paid to you will be
withheld for federal income taxes. State taxes will be withheld where applicable. You must submit a Form W-4P (available
at, if you select a different form of distribution. State and federal taxes withheld will be reported on a form 1099-R.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications
required to avoid backup withholding.
I consent to a distribution as elected above. I understand that the terms of the plan document will control the amount
and timing of any payment from the plan. Further, I certify that I have read and received the attached Special Tax Notice
Regarding Plan Payments. If I elect to receive this distribution before the end of the 30 day minimum notice period, my
signature on this election form shall constitute a waiver of my rights to the 30 day notice requirement, if applicable.
Participant Signature:
Local Office Authorization Signature
Public Safety Officer
c Yes c No
Form Return
Nationwide Retirement Solutions
4747 N. 7th Street, Suite 418
Phoenix, AZ 85014
DC-2474 (8/2016)
Fax: 602-650-1278
For help, please call 800-796-9753
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