Qualified Plan Beneficiary Claim Form

Mailing Address:
P.O. Box 8963
Wilmington, DE 19899-8963
800-209-9010 Fax: 302-999-9554
[email protected]
Qualified Plan
Beneficiary Claim Form
Important Information
This form is only to be completed in cases where the account holder is deceased. Based on the beneficiary relationship
we require additional information outlined below.
If the beneficiary is:
We need:
Spouse
Non-Spouse
Trust
Estate
I.
- Certified copy of the death certificate
- Certified copy of the death certificate
- Guardianship paperwork and letter of authorization from the guardian if beneficiary is a minor
- Certified copy of the death certificate
- A copy of the fully executed Trust that clearly identifies all of the beneficiaries and the trustee
- Tax ID number for the Trust
- Certified copy of the death certificate
- Letters of Testamentary or Letters of Administration
- Tax ID number for the Estate
Plan Sponsor Information (Please print or type)
Plan Name
Plan Type
Profit Sharing
Participant (Decedent) Name
Investment Firm
Account Number
Participant’s Social Security Number
Participant’s Date of Death
Participant’s Date of Birth
Was the participant married at least one year when the death occurred?
II.
Pension
Plan Number
Individual 401(k)
% Awarded
Participant’s Outstanding Loan Balance
Participant’s Date Last Worked
Yes
No
Beneficiary Election (To be completed by the Beneficiary)
Note: If more than one beneficiary, each beneficiary must complete a separate claim form.
Beneficiary Name
Relationship to Decedent
Beneficiary Address
City
Social Security Number / EIN for Trust or Estate
Date of Birth
State
ZIP Code
Daytime Phone Number
Many options are available to you as the beneficiary of a participant’s retirement plan. You may choose one of
the following distribution options. Please consult your tax or legal advisor if you have any questions regarding
which choice is best for you.
Deferred Decision (Go to Section III)
You may choose to defer your decision about this benefit until December 31 of the year following the Participant’s
death. The retirement benefit/account and investment return will not be taxed until distributed. Complete Section III
Beneficiary Designation below if you choose this option.
Direct Rollover to Inherited IRA (Non-Spouse) or Direct Rollover to an IRA or Qualified Plan (Spouse):
(Go to Section IV) This provides us with the Distribution Type and Distribution Method.
Cash Distribution (Go to Section IV)
You may choose to have a lump sum cash distribution paid to you. Your distribution will be subject to mandatory
20% withholding as required by law. You may avoid this withholding by electing a direct rollover to an eligible
retirement plan. If you live in a state that requires state tax withholding, that amount may be deducted also.
Delaware Charter Guarantee & Trust Company d/b/a Principal Trust Company
TR 344-2
Page 1 of 2
01/2010
III. Beneficiary Designation (Complete only if “Deferred Decision” was selected above)
I designated the following as my beneficiary(ies) to receive benefits payable under the plan in the event of my death.
This beneficiary designation will supercede any and all previous beneficiary designations.
Note: Please check the appropriate Primary or Contingent box for each beneficiary.
Primary
Contingent
Primary
Contingent
Primary
Contingent
Name
Social Security Number
Date of Birth
Allocation
Relationship
Street Address
City
State
ZIP Code
Phone Number
Name
Social Security Number
Date of Birth
Allocation
Relationship
Street Address
City
State
ZIP Code
Phone Number
Name
Social Security Number
Date of Birth
Allocation
Relationship
Street Address
City
State
ZIP Code
%
%
%
Phone Number
IV. Distribution Information (Please select from each of the Event, Method, and Type options)
This will be a:
Total Distribution
Partial Distribution in the amount of $ _________________
Distributable Method
Distribution Type
In-Cash (liquidating assets)
In-Kind (reregistering assets/certificate form)
V.
Direct Rollover to another Qualified Plan
Direct Rollover to IRA
Payment Information
Note: All distributions will be issued to the Beneficiary and mailed to the address in Section II unless directed otherwise
in this section.
Make Check Payable and Issue to: Financial Institution, Qualified Retirement Plan, or Personal Account Information
Name of Financial Institution
Plan Type
Mailing Address
City
401(k)
Account or Identification Number
Name of Contact at Financial Institution
Profit Sharing
Pension
State
IRA
ZIP Code
Phone Number
VI. Beneficiary Signature
I have received a written explanation of the special tax rules for distributions eligible for rollover treatment as described in
§402(f) of the code (“§402(f) Notice”) from the plan sponsor. I have reviewed the notice and understand the information
provided.
Federal tax law requires a payment cannot be made any sooner than 30 days, nor later than 180 days after I receive the
§402(f) Notice. However, my signature below is an affirmative election for the distribution option chosen on this election form
and reduces the 30-day waiting period to 7 days as allowed by law. I understand if 180 days has passed since I received the
§402(f) Notice, I should request another copy to restart the time limit described above. I certify that I received the §402(f) Notice
on the date I signed the form, unless I enter a different date here ______________.
I understand the relationship between my benefit election(s) and income tax withholding and have consulted a tax advisor, if
necessary. I certify the information I provided on this form is accurate and complete. This election cancels any prior election I
made under this Plan.
Beneficiary’s Signature
Date
Witness by Notary Public
Date
If Notary Public, Commission Expires
VII. Plan Sponsor Signature
I certify the above information is true and correct. I authorize Delaware Charter Guarantee & Trust Company d/b/a Principal
Trust Company (to make a distribution to this Beneficiary of the current account balance, plus future benefits that may be
credited to the participant’s account, according to the terms of our plan.
Plan Sponsor (Print Name)
Title
Plan Sponsor Signature
Date
Delaware Charter Guarantee & Trust Company d/b/a Principal Trust Company
TR 344-2
Page 2 of 2
01/2010