DEFINED BENEFIT FORM OF LOSAP II BENEFIT ELECTION

DEFINED BENEFIT
FORM OF LOSAP II BENEFIT
ELECTION AGREEMENT
Plan Name:
Date of Participation
Participant’s Name:
Date of Birth
Social Security #:
Home Phone #:
The undersigned wishes to elect the form of Service Award Benefit which will be payable under the
Length of Service Award Program II (“Program”) referenced above. All terms contained in this
Election Agreement and defined by the Program shall have the meanings ascribed to them by the
Program.
1. Applicability of Plan - I understand that this Election Agreement and all terms and conditions of my
participation in the Program and my rights to amounts credited to me are subject to the provisions
of the Program.
2. Taxation of Benefits - I understand that all amounts received by me under this Program are taxable
to me as ordinary income in the year received.
3. “Length of Service Award Benefit II” - When payable will be:
Lump Sum. Please complete Putnam Small business 401K distribution form attached.
4. Effective Date and Change of Election - The Election Agreement shall be effective on the date it is
signed by me.
________________
Date
_____________________________________________________
Participant’s Signature
Please Mail Check To:
MCNEIL & COMPANY
ATTN: BRIAN FOX
20 CHURCH STREET
P.O. BOX 5670
CORTLAND, NY 13045
(800) 822-3747 Ext. 142