457 Plan Automatic Enrollment 90-Day Permissible Withdrawal Form

457 Plan Automatic Enrollment 90-Day Permissible Withdrawal Form
Use blue or black ink only
Commonwealth of Virginia Deferred Compensation Plan
Commonwealth of Virginia Cash Match Plan
98987-01
98987-02
Participant Information
Social Security Number
Last Name
First Name
MI
Employee Number
(if applicable/9-digit mandatory for state CIPPS agencies)
(
)
(
)
Home Phone
Work Phone
E-Mail Address
Married
Unmarried
Are you a U.S. citizen or
Yes
No
resident alien?
Mo
Day Year
Date of Birth
Your distribution will be mailed to your address on file. You may confirm the address on file by accessing your account online at www.vadcp.com. Or by
calling Keytalk toll free at 1-866-226-6682
If you have recently changed your address or have any questions regarding the address on file, please contact your agency’s payroll office.
Distribution Reason
90-Day Permissible Withdrawal – due to automatic enrollment into the Plan via an eligible automatic contribution arrangement.
This type of distribution is allowed if your salary deferrals have been defaulted by your employer through the Plan’s eligible automatic
contribution arrangement. To qualify for this withdrawal you must take the following actions.
1.
2.
Opt out of automatic enrollment online at www.vadcp.com or by calling KeyTalk® toll free at 1-866-226-6682 and
Send this completed request to be received by Great West Retirement Services® at the address on the last page of this
form no later than 90 days after the payroll date in which the first automatic deferral is made on your behalf under the Plan’s
eligible automatic contribution arrangement.
Any employer match attributable to this distribution of your default elective contributions will be forfeited. The amount of the
distribution will be the value of your defaulted elective contributions plus or minus investment gains or losses.
Distribution Delivery
Check
Express Delivery - $25.00 non-refundable charge - Express delivery available Monday through Friday only. Not available to P.O. boxes.
ACH - Available on a lump sum payment to self for a $15.00 non-refundable charge.
Checking Account - must attach preprinted voided check.
Saving Account - must attach preprinted voided deposit slip.
Financial Institution Name
Account Number
ABA Number
Financial Institution Mailing Address
City
State/Zip Code
Last Name
First Name
MI
Social Security Number
Plan Number
Federal and State Income Tax Withholding
Federal Income Tax – 10% withholding will be withheld unless you request additional Federal Income Tax withholding or opt out of Federal Income
Tax withholding
If you would like additional federal income tax withheld, indicate amount. $
or
% of the distribution amount.
Do NOT withhold federal income tax from my 90-day permissible withdrawal.
State Income Tax - If you live in a state that mandates state income tax withholding, it will be withheld.
Check here if you live in a state that does not mandate state income tax withholding and would like state income tax withheld.
If you would like additional state income tax withheld, indicate amount. $
or
% of the distribution amount.
Note: If you do not make an election above, state income tax will not be withheld unless you reside in a state that mandates state income tax
withholding.
Required Signature
Any person who knowingly presents a false or fraudulent claim is subject to criminal and civil penalties.
My signature acknowledges that I have received, read, understand and agree to all pages of this 90-Day Permissible Withdrawal form, and affirm that all
information that I have provided is true and correct. I understand that funds may impose redemption fees on certain transfers, redemptions or exchanges
if assets are held less than the period stated in the fund's prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure
documents for more information. I understand that it is entirely my responsibility to ensure that this election conforms with all applicable provisions
of the Internal Revenue Code (the "Code). I understand that I am liable for any income tax and/or penalties assessed by the IRS for any election
I have chosen. I understand that once my payment has been processed, it cannot be changed. In the event that any section of this form is
incomplete or inaccurate, Service Provider may not process the transaction requested on this form and may require that I complete a new form or
provide additional or proper information before the transaction can be processed.
I understand that to qualify for a distribution of automatic deferrals from the 457 Plan I must:
1. Opt out of the Plan online at www.vadcp.com or by calling KeyTalk® at 1-866-226-6682
2. Complete and sign this form and mail it to the Great West Retirement Services® address below to be received no later than 90 days
after the pay date on which the first automatic deferral was taken from my pay.
Participant Signature
Date (Required)
Participant forward Form to:
Great-West Retirement Services®
1108 East Main St, Suite 1102
Richmond, VA 23219
OFFICE USE ONLY
_______________________________________________________________________________________________________________
I certify that this request is in compliance with applicable Plan provisions and federal law and that the participant has received from me any notices required
by law. Service Provider is authorized to forfeit any employer match contributions associated the 90-day permissible withdrawal.
I approve this 90 Day Permissible Withdrawal
This request for withdrawal is denied for the following reasons:
________ The employee did not opt out of automatic enrollment within the required time
__________ The employee took active control of his account by changing the deferral prior to this request for withdrawal being processed
_________ The request for withdrawal was not received within the required time
_________ Other:________________________________________________________________________________
Great-West Retirement Services® refers to products and services provided by Great-West Life and Annuity Insurance Company, FASCore, LLC.
Authorized Plan Administrator/Trustee Signature
Great-West Retirement Services® will obtain Plan
Administrator/Trustee Signature
Date
Last Name
First Name
MI
Social Security Number
Plan Number