Buchanan Hauling 401(k) Plan 517326-00000
Rollover Form
Five Simple Steps 1. Contact your plan administrator or refer to your Summary Plan Description to make sure you're eligible to roll over your plan account balance from a prior qualified retirement plan. 2. Contact your prior company and request a rollover distribution. If you have an Individual Retirement Account (IRA), contact the investment manager (custodian) for your IRA and request a withdrawal. Be sure to have the distribution check made payable to Transamerica, FBO "Reference Your Name" (e.g., Transamerica, FBO Jane Doe) and have it sent directly to you. 3. Complete the Rollover Form below. 4. Submit the Rollover Form along with the distribution check to your plan administrator. 5. Your plan administrator will sign, date, and submit the form and check to Transamerica for processing.
You must first enroll in the plan and designate a beneficiary.
1. Employee Information
(Please print)
__ __ __ - __ __ - __ __ __ __
Married
Not Married
Social Security No.:
First Name
M.I.
Last Name
Mailing Address
Apt. No.
City
State
Zip Code
Date of Birth
Date of Hire
Telephone Number
Email Address
2. Previous Plan/IRA Information
Name of prior plan________________________________________________________________________________________________________
Mark One:* O O O O O O 401(k) 403(a) 403(b) Profit Sharing Plan Defined Benefit Plan Money Purchase Plan O O O O O O O Government 457 Conduit IRA Traditional IRA Simple IRA SEP IRA Roth 401(k) - Direct Roth 401(k) – Indirect (earnings only permitted)
For Roth 401(k) rollovers, please complete the information below. This information should have been provided by your rollover institution.
Year of First Roth 401(k) Contribution __________________________
Roth Contribution Basis _____________________________ (This is the non-taxable portion of your distribution). *Your plan may not accept rollovers from all plan types listed above. Contact your plan administrator to make sure your rollover qualifies. The tax costs with a Roth IRA conversion can be significant. Contributions are subject to taxes that were previously deducted, including any accumulated earnings. You may also be pushed into a higher tax bracket, especially if converting a large amount of money.
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517326-00000 09/07/2017
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