Buchanan Hauling 401(k) Plan Rollover Form
Social Security No.: __ __ __- __ __ - __ __ __ __
Previous Plan/IRA Information Contact:
First Name __________________________________________________________________________________ M.I. ________________________
Last Name _______________________________________________________________________________________________________________
Mailing Address ______________________________________________________________________________ Apt. No. ____________________
City ____________________________________________________________ State _______________________ Zip Code ___________________
Telephone Number _________________________________________
3. Tax Information c All of this distribution amount would be taxable to me if I did not roll it over. c This rollover includes after-tax contributions in the amount of $ ________________________. The remainder would be taxable income to me if I did not roll it over. c No part of this rollover is a minimum required distribution. c No part of this rollover is a hardship withdrawal. Please note the following important information: 1. Transamerica cannot accept after-tax amounts if the cost basis is not provided. if you are unsure of your after-tax cost basis, contact your previous plan administrator to obtain/confirm this information. If this information is not received, it will be assumed that the deposit represents pretax amounts only. 2. If you are already enrolled in the plan, your incoming rollover will be invested according to your existing investment allocation for payroll contributions. 3. If you are not enrolled in the plan, or your elections do not equal 100%, your incoming rollover will be invested in PortfolioXpress ® . You can subsequently reallocate your investment at any time, subject to plan provisions. 4. Employee Authorization I wish to contribute a single sum rollover in the amount of $ _____________, which represents a distribution from another qualified retirement plan. A check made payable to Transamerica, FBO "Reference Your Name" (e.g., Transamerica, FBO Jane Doe) is attached. I understand the withdrawal restrictions that apply to these contributions. Employee signature___________________________________________________________ Date____________________________________ SUBMIT SIGNED FORM TO YOUR PLAN ADMINISTRATOR Once this form has been completed with all of the necessary information and required signatures, please forward to the Transamerica Processing Center. Please list the name, contract # and SSN last 4 digits on the check & any other documents sent with the rollover form. Be sure to keep a photocopy for your records.
For Plan Administrator Use Only: I authorize these rollover funds to be deposited into the participant's account.
Plan Administrator Signature __________________________________________________
Date _____________
For PLAN ADMINISTRATOR USE ONLY : JPMorgan Chase – Lockbox Processing 13029, 4 Chase Metrotech Center 7th floor East, Brooklyn, NY 11245 Fax#: 866-846-2236
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517326-00000 09/07/2017
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