HomeMy WebLinkAbout2011 02 22 Other - Related to Agenda Item 600 Survivor Annuity Benefit Correction for Ms. Nellie P. Pilcher Board of Trustees
Special Meeting
February 22, 2011
The attached documents were distributed related to Agenda
Item "600" Requesting Approval for a Survivor Annuity
Benefit Correction for Ms. Nellie P. Pilcher.
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For, W -4P Withholding Certificate for OMB No 1545 -0074
Pension or Annuity Payments
Department d the Treasury ( Q J 1 0
Interne Revenue Service
Purpose. Form W -4P is for U.S. citizens, resident aliens, or their pages 3 and 4. Your previously filed Form W -4P will remain in effect
estates who are recipients of pensions, annuities (including if you do not file a Form W-4P for 2010.
commercial annuities), and certain other deferred compensation. Use What W from tell payers the correct amount of federal income - hat do I need to do? Complete lines A through G of the Personal
W tax
to withhold from your payment(s). You also may use Form W-4P to Allowances Worksheet. Use the additional worksheets on page 2 to
choose (a) not to have any federal income tax withheld from the further adjust your withholding allowances for itemized deductions,
payment (except for eligible rollover distributions, or payments to adjustments to income, any additional standard deduction, certain
U.S. citizens delivered outside the United States or its possessions) credits, or multiple pensions/more- than - one - income situations. If you
or (b) to have an additional amount of tax withheld. do not want any federal income tax withheld (see Purpose above),
Your options depend on whether the payment is periodic, you can skip the worksheets and go directly to the Form W -4P
nonperiodic, or an eligible rollover distribution, as explained on below.
Sign this form. Form W -4P is not valid unless you sign it.
Personal Allowances Worksheet (Keep for your records.)
A Enter "1" for yourself if no one else can claim you as a dependent A
• You are single and have only one pension; or
• You are married, have only one pension, and your
B Enter "1" it: spouse has no income subject to withholding; or B
• Your income from a second pension or a job, or your
spouse's pension or wages (or the total of all) is $1,500 or less.
C Enter "1" for your spouse. But, you may choose to enter " -0-" if you are married and have either a spouse who
has income subject to withholding or you have more than one source of income subject to withholding. (Entering
"-0-" may help you avoid having too little tax withheld.) C
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . D
E Enter "1" if you will file as head of household on your tax return E
F Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $61,000 ($90,000 if married), enter "2" for each eligible child; then less "1"
if you have three or more eligible children.
• If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter "1" for each
eligible child plus "1" additional if you have six or more eligible children F
G Add lines A through F and enter total here. (Note. This may be different from the number of exemptions you claim
on your tax return) ► G
• If you plan to itemize or claim adjustments to income and want to reduce your withholding,
For see the Deductions and Adjustments Worksheet on page 2.
• If you have more than one source of income subject to withholding or a spouse with income
subject to withholding and your combined income from all sources exceeds $18,000 ($32,000 if
all married), see the Multiple Pensions/More- Than - One - Income Worksheet on page 2 to avoid
S having too little tax withheld.
that apply. • If neither of the above situations applies, stop here and enter the number from line G on line 2
of Form W-4P below.
Cut here and give Form W-4P to the payer of your pension or annuity. Keep the top part for your records.
Form W-4P Withholding Certificate for OMB No. 1545-0074
Pension or Annuity Payments 201 O
In Internal ernal Revenue Service le ent a ea
the Trsury
I For Privacy Act and Paperwork Reduction Act Notice, see page 4.
Type or print your first name en \� m � itltlie initial �ysI name =List °^r`urity number
SA)
I e-c\ . P \ \ t
Home,�ddresg.fnumber_ and street or rural route) Claim or identification number
1 l A 7 \ c c 4 . 3 (if any) of your pension or
annuity contract
City or_to s te, and ZIP code [. ` q
\.) a) f�.. 1 1 . tom`- t�
( 53
Complete the following applicable lines.
1 Check here if you do not want any federal income tax withheld from your pension or annuity. (Do not complete lines 2 or 3.) ■ ❑
2 Total number of allowances and marital status you are claiming for withholding from each periodic pension or yy
annuity payment. (You may also designate an additional dollar amount on line 3.) ► -L-
Marital status: gl Single ❑ Married ❑ Married, but withhold at higher "Single" rate (Enter f f
3 Additional amount, if any, you want withheld from each pension or annuity payment. (Note. For periodic payments,
you cannot enter an amount here without entering the number (including zero) of allowances on line 2.) . . 0" $
Your signature ► , _ � Date ► '7- (q - ( 0
Cat, No. 10225T Form W - (20101
Carff PilcFter - l 1815
Nellie i r 63- 751/631
P 0 Box 5 3 483 BRANCH 03014
Defany, FL 32753
_ DATE
PAY TOTHE O
ORDER OF p
_ / _ DOLLARS el
wacxovra
Wachovia Bank, NA.
wachovia.com
FOR - - - - we
PARTICIPANT DISTRIBII'IION El,E( "[TON
(l' 3 able of restcd accrued benefit exceeds S5.000)
To the Plan Administrator of the Defined Benefit Plan and Trust for Employees of Winter Springs,
Florida ( "Plan ").
Re: _. Carl Pilchcr , Participant
1. Election. 1, the undersigned Participant, have read the "Notice to Participant of Distribution Election" and
the "Special Tax Notice Regarding Plan Payments" and make the following distribution election: ( Choose (a)
or (b))
n (a) Qualified Annuity Benefit. I elect to receive the Qualified Annuity Benefit, as explained to
me. [Note: If you elect (a), complete sections 2 and 3 no other section.]
n (b) Waiver of Qualified Annuity Benefit. I waive the Qualified Annuity Benefit and instead
elect: (Choose one of the following)
n (1) A straight life annuity payable for your life.
(2) Joint and survivor annuity benefit, with a survivor annuity of-
50% ($1017.39) 75 %(981.11) 100% (947.33)
n (3) An annuity payable for your life with a term certain guaranteed.
n (4) Installment or annuity payments.
if you chose (b)(2), (b)(3), or (b)(4) Please ask the Plan Administrator to provide you the necessary form for
electing an installment or annuity payment method.
lMarital status. I am: (check one) Vrnarried not married.
Note: If you are married and you elected (b), your spouse must complete section 4.
3. Execution. Dated this , O day of , 2006
Your SignaIUi4/fj
Your Social Security Number:
Address:
pc AYAy // J..27/3
M \DATAtwINwoRD I;Rii)13I 1 X.Ikx;J'II.CI il:le i.n()C•OR9S
ELECTION FOR INSfAI.1. \IENl OR ANNUITY DISTRIBUTION
I a Mc I'I:m Admmr:u.uc,r of the Defined Benefit Plan and 'trust for Employees of Winter Springs, Florida ( "flan ").
I:c Carl filcher . Participant.
1. Election. I, the tin lei gncd Participant, have elected to receive my entire Vested Accrued Benefit in installments or in an annuity
form as determined in Section 2.
2. Distribution Term. (( ',anpletc (t+) and lb))
I request payments (monthly quarterly annually
(h) I elect the fnllowmg distrt wtiott tel (choose (I), (2). (3), (4) or (5))
�] (1) My till expectancy, as determined under Treasury regulations: (Choose (i) or (ii))
n (1) determining my life expectancy once, when I commence distribution.
recalculating my life expectancy each year.
�i (2) The joint life and last survivor expectancy, as determined under Treasury regulations, of my designated beneficiary
and me: (Choose (i) or at least one of (ii) and (iii)).
n (I) determining the joint expectancy term once, when 1 commence distribution.
( (ii) recalculating the joint expectancy term by adjusting my life expectancy on an annual basis.
�] (iii) recalculating the joint expectancy teen by adjusting my spouse's life expectancy on an annual basis. [Note: You
cannot elect (iii) unless your spouse is your designated benefician•-]
[�] (3) A hie annuity.
(� (4) A life annuity with guaranteed payments of years.
(5) A Joint t Survivor Annuity (50% i 75% 100%
If l am over 70% years of age, I understand any payments for a calendar year under (1), (2), (3), (5) or (6) will adjust if necessary to
satisfy the minimum distribution requirements under the Plan.
.Vote: You may not revoke (l)(i). (1)(ti). (2)(i), (2)(ii) or (2)(iii) after you attain age 70'/..
Dated this c2 D day of AM46, , 20 O O .
Your Signature:
Your Social Security Number:
Your Address: /i 8 , Ate -. 7 a e"L" .de 14 - .ry r/
377/3
Now: You must attach this form to the Participant Distribution Election Forts you have completed.
•nor: r.wiNsvOItox:t.tr n [11)1 rn :rat nrx,na„
NOTICE TO DISTRIBUTE PARTICIPANT'S ACCRUED BENEFIT
To' the Trustee of Money Purchase Pension Plan and Trust for Employee of the City of Winter Springs, Florida ( "Plan "):
Re: Carl Pilcher , Participant
In accordance with Article VI of the Plan, the Plan Administrator of the Plan hereby directs you to distribute the above
Participant's Vested Account Balance to:
Carl Pitcher
Name of Participant/Beneficiary SS Number
118 Pine Tree Drive Debary, Florida 32713
Participant's /Beneficiary's Address
12/31 /99 S $
Valuation Date Vested Account Balance Total Account Value
Please make the distribution as soon as administratively feasible.
A. Form of Distribution. You should pay the Participant's Vested Account Balance:
[ 1 (1) In lump sum.
[X] 2) In accordance with the distribution election form attached to this Notice.
B. Transfer of Insurance Contracts. If any part of the Participant's Account Balance consists of incidental benefit life
insurance contracts, you should make any transfer of insurance contracts as required under Section 11.02 of the Plan. If the
distribution of the Participant's Accrued Benefit is in lump sum, the transfer of any insurance contract should occur in the same
taxable year of the Participant in which you complete the lump sum distribution.
C. Consents /Forfeitures. If the distribution is to the Participant and the Participant is less than 100% vested in his Account
Balance, this distribution will result in an immediate forfeiture of the Participant's nonvested Account Balance, in accordance
with Article V of the Plan. If the distribution requires the consent of the Participant or of the Participant's spouse, we have
attached the appropriate election forms evidencing the necessary consent(s).
Vat
Dated this day of a , 20 00.
CITY OF WINTER SPRINGS,
PLAN ADMINISTRATOR
By: • 4-2_.,.A --/1
Print Name: Ronald McLemore
This Notice to Distribute received this day of , 19 .
TRUSTEE:
By: , Trustee
Print Name of Trustee
?I:' 1)..11A.WINWOHILI'LIE?ll ] 1 PH'.I, 61, I' X 11 S1 17(K 499
1'AR'fl('IPANf 1)151 kIBLTION ELECTION
( I' , cI d vermin, ha /,our avcrccic 55.000)
I u the flan Administrator of the Money Purchase Pension Plan and Trust for Employees of the Cit of
Winter Springs, Florida ("Plan").
RE: Carl Pitcher Participant Name
--mac -
March 29, 2001) Date of (Circle) Termination Retirement Disability
I. Election. I, the undersigned Participant, have read the "Notice to Participant of Distribution Election" and
the "Special Tax Notice Regardine,Plan Payments" and make the following distribution election: (Choose (a)
or (b))
n (a) Qualified Annuity Benefit. I elect to receive the Qualified Annuity Benefit, as explained to
me. [)Note: If you elect ('a), complete section 3 and no other section.]
n (b) Waiver of Qualified Annuity Benefit.] waive the Qualified Annuity Benefit and instead
elect: (Choose (1), (2), (3) or (4))
n (1) A direct rollover of my entire Vested Account Balance to the IRA or plan
designated in Section 2.
n (2) A direct rollover of the following portion of my Vested Account Balance to the IRA
or plan designated in Section 2: (nut less than S500), with the balance paid in
lump sum (less income tax withholding).
F (3) A lump sum payment of my entire Vested Account Balance less income tax
withholding.
I (4) Installment payments. Please provide me the necessary form for electing an
installment payment method. Note: The installment method election form will permit you to
split your distribution between installments and lump stmt and to elect a direct rollover of
any payment which is an eligible rollover distribution.]
1 (5) A 100% joint and survivor annuity.
j / (6) A direct transfer of my entire Vested Account Balance to the Defined Benefit Plan
jjj and Trust for Employees of the City of Winter Springs (the "Defined Benefit Plan ") under
this election, I understand that my Vested Account Balance will be utilized to provide
additional benefits under the Defined Benefit Plan which will be reflected on the
distribution forms I complete for the Defined Benefit Plan.
If I am less than 100% vested in my Account Balance. I understand (b)(4) is not available and a distribution
results in a forfeiture of the nonvested portion of my Account Balance, subject to the repayment/restoration
rights explained in the "Notice to Participant of Distribution Election."
2. Information for Direct Rollover. [Do not complete unless you check l.(b)(1) or 1.(b)(2)1
I represent the IRA or plan designated below is a proper recipient plan for a direct rollover.
Name of IRA or plan
If an IRA, name of trustee, custodian or insurer
Address to send direct rollover
ntr.DAFNAVINWOuD mvr.wivreuvi.DOC IN u0c
I
. .Waiver of minimum notice period. I consent to an immediate distribution of my Vested Account
Balance. I affirmatively waive any unexpired portion of the minimum 30 -day notICC period during which I
may consent to a distribution from the Plan.
14.1Marital status. I am: (check one) /married not married
Note: if you are married and you elected (h), your mum compI e!C se con 6
5. Execution. Dated this i20 _ day of 1»'f C // , 20 CC
PARTICIPANT SIGNATURE Participant Social Security Number
•
// 2 0 ivr its r E 02,e ✓t Di �/ 30 7/3 -
Street City ST 'Lip
6. Consent of Spouse l� �[ CA
(P N . 11: o YiCF{o vs a �] _ ___(prinl name), spouse of the Participant hereby consent
to the waiver of the Qualified Annuity Benefit and to the timing and form of distribution elected on this
form. I have received a written explanation of the Qualified Annuity Benefit, my right not to consent to this
waiver election, the waiver election period, and the financial effect of the election not to receive benefits in
the Qualified Annuity Benefit form. I understand my consent is irrevocable unless my spouse revokes the
. waiver election. I understand any change in this form of benefit election is subject to my consent, unless my
spouse elects to receive the Qualified Annuity Benefit.
I have executed this election this z o day of M n r , 20 00 .
Signature of Spouse fLD
Note: If the spouse completes section 6, a proper witness must complete either section 7 or section 8.
7. W by Plan Representative. Signature of spouse for consent witnessed this oed day of
/1(Qcl'� , 20 a9 .
Plan Repre five
8. Witness by Notary. l G i i ✓ L `C
STATE OF FLORIDA
(ss.
COUNTY OF ((
SWORN TO AND SUBSCRIBED before me this day of , 20_, by
, who is personally known to me or who has produced
(type of identification as identification)
and who (did / did not) take an oath.
Signature
(Print Name) Notary Public
My Commission Expires:
Commission Number:
7
\1.�.nAT.1 \1V1 \RVORD)l'LIIV IIIVIN rI:R)I l.nol:.l'I `
NOTICE TO DISTRIBUTE PARTICIPANT'S ACCRUED BENEFIT
To the Trustee of the Defined Benefit Plan and Trust for Employees of Winter Springs, Florida ( "Plan "):
Re: Carl Pitcher , Participant
In accordance with Article X of the Plan, the Advisory Committee of the Plan hereby directs you to distribute
the above Participant's Vested Accrued Benefit to:
Name of Participant/Beneficiary Carl Pilcher/Nellie Pilcher
SS Number:
Participant's/Beneficiary's Address
Vested Accrued Benefit payable at normal
retirement age under normal form of benefit Vested Percentage in Accrued Benefit: 100%
described in Article V: $1098.65
Valuation Date: 12/31/99
Please make the distribution on April L 7000 __._ ____ _ _ or as soon as administratively practicable
following that date.
A. Form of Distribution. You should pay the Participant's Vested Accrued Benefit:
[ ] (1) In lump sum.
[X ] (2) In accordance with the distribution election form attached to this Notice.
B. Consents/Forfeitures.If a lump sum distribution is to the Participant and the Participant is less than 100%
vested in his Accrued Benefit, this distribution will result in an immediate forfeiture of the Participant's nonvested
Accrued Benefit, in accordance with Article VIII of the Plan. If the distribution requires the consent of the
Participant or of the Participant's spouse, we have attached the appropriate election forms evidencing the necessary
consent(s).
Dated this CI - day of __ ' , 2000. ` ✓(
Advisory Committee
By: Ronald WI emnre
This Notice to Distribute received this day of , 2000.
TRUSTEE
By:
4. Consent of Spouse
I. _dam' e.,_V iS\Cs=r:.)__ 5:; —r __ __ . spouse of the Participant hereby consent
to the waiver of the Qualified Annu Benefit and to the timing and form of distribution elected on this
form. 1 have received a written explanation (tithe Qualified Annuity Benefit, my right not to consent to this
waiver election, the waiver election period, and the financial effect of the election not to receive benefits in
the Qualified Annuity Benefit form I understand my consent is irrevocable unless my spouse revokes the
waiver election I understand any change in this form of benefit election is subject to my consent, unless my
spouse elects to receive the Qua lif ied Annuity Benefit.
I have executed this election this Z O day of s 20 vo.
‘ \.n.S? D . 'V
Signature of Participant's Spouse
Note: If the spouse completes section 4, a proper witness must complete either section 5 or section 6.
5. Witness by Plan Representative. Signature of spouse for consent witnessed this ,30 day of
/" dite,U' 201/()
Plan Representativcy C. AZit-it—
6. Witness by Notary.
STATE OF FLORIDA
(ss.
COUNTY OF
SWORN TO AND SUBSCRIBED before me this _ day of , 20
by
who is personally known to me or who has produced
(type of identification as identification) and who
(did/did not) take an oath.
Signature
(Print Name) Notary Public
My Commission Expires:
Commission Number:
Si. 551 A'.W INWOIO5.I'i.iIiN11W tN rL12,u111 I X 1)1)1' PILCI Ir.R\A.15(5 .55982
FIFTH THIRD BANK
BENEFIT PAYMENTS — Periodic Payments — Set up or Change Request
Plan Name City of Winter Springs Defined Benefit Pension Plan Bank/Pay Group
Benefit Payment Set Up Change Request
Complete all appropriate sections of this form and return to:
Fifth Third Bank, Retirement Distribution Services
5001 Kingsley Drive MD 1MOBB2, Cincinnati, OH 45227
Please print clearly, all fields marked by an * are required
Please have participant sign Section G at end of form for Residency Information
If section G is not complete the form will not be processed
A. Participant Information
_
JELLIE P. FI:
*Name: *Social Security#: _ *Date of Birth:
*Home/Tax
Address: n. o. Box 530483
DEBARY FL 32753
*City. — *State: *Zip Code:
*Mailing
Address: SAME
*City: — *State: _ -- *Zip Code:
B. Benefit Information
BENEFICIARY OF DECEASED (CARL FILCHER)
*Reason for Distribution: *Hire Date:
*Benefit Amount: 1 ' 1 39 *Participation Date:
*Non Taxable: *Termination Date:
, e /u1 /?c:a
*Taxable: *Benefit Start Date:
Distribution Code: — _ _ *Benefit Stop Date: N/A
*Is Participant entitled to a
MONTHLY
retro payment YES / NO *Frequency:
(If yes, the following fields are required)
Retro Payment Amount: $1,017.39
Retro Payment for dates: 08 / 01/ 1°through 0E 31 j 0
Benefit Payment Available Under the Following Plan Option:
C. Federal Income Tax Withholdi g IRS form W -4P must be attached for all payments of U.S. Citizen /Resident Alien
Marital Status Dependents
No Withholding Fixed Amount: $ Percentage: %
* *See Section G if participant is a Non - resident Alien (IRS form W -8BEN is required)
Revised 7/09 (over)
FIFTH THIRD BANK
r,:= ,, r,:LL',,LE P. IILCHER
Parti(]Oda Name PaiIitha^t.5514 D. Optional State Income Tax Withholding State withholding form must be attached for all payments
Marital Status Dependents
F No Withholding I Fixed Amount: $ I I Percentage:
F. Additional Deduction Information as Plan allows:
Deduction Amount
G. Participant Residency Instructions
Please check your correct tax status:
U. S. Citizen /Resident Alien (complete IRS Non- Resident Alien (complete IRS form W-
form W -4P) 8BEN)
Is payment to be delivered to an address or account outside the United States? _ __ Yes No
If you are a non - resident alien please complete the attached IRS Form W8 -BEN by following the instructions provided, and return
with the payment request. If IRS Form W8 -BEN is not included. withholding will be processed at 30% of the nross
payment.
If you are a U. S. Citizen /Resident Alien, please complete the IRS From W by following the instructions provided and include
with the payment request. If IRS form W -4P is not included. withholding will be processed assuming a marital status
of Married /Joint with 3 exemptions.
Participant NEXT PAGE
Signature: Date:
Printed Name:
H. Plan Sponsor authorization
1 have reviewed the Plan Document and authorize payment based upon provisions allowable by that document.
f
/ r
Authorized by: - / v Date: a,/zZi
RF,VIN L. SMeTN 407- 327 -5962
Printed Name: Telephone #:
Email address: Company Name: CITY OF WINTER SPRINGS
For Fifth Third Use Only Check Number: Check Date:
Input by: _ -- --- - -- - - --
Verified by: - -- — - - - - -- - -----
Released by:
Release Verified by:
Checks Verified by:
Checks received by: - - --
Revised 7/09
FIFTH THIRD BANK
Residency Information
Plan Name City of Winter Springs Defined Benefit Pension Plan Bank/Pay Group'_
If this form is not completed and sent with payment request the payment will not be
processed
Please complete all items marked with an *
A. Participant Information
*Name:
NELLIE F. FILCHER LCHER *Social Security*: *Date of Birth: 03/13/1940
`Home/Tax
Address: P. • 20): 530483
DEEMet *State: FL _ *Zip Code: 32703
*Mailing SAME
Address: — — — — — — —
*City' - -- *State: *Zip Code: —
B. Participant Residency Information
Please check the correct tax status:
xxxxx U. S. Citizen /Resident Alien _ Non- Resident Alien
Is payment to be delivered to an address or account outside the United States? - __- Yes xxxx No
if you are a Non - Resident Alien, please complete the IRS Form W8 -BEN by following the instructions provided, and include with the
payment request. If IRS Form W8 - BEN is not included. withholding will be processed at 30% of the gross payment,
If you are a U. S. Citizen /Resident Alien, please complete the IRS Form W by following the instructions provided and indude
with the payment request. jf IRS Form W-4P is not included, withholding will be processed assumino a marital status
of Married /Joint with 3 exemptions,
Participant (� n .A
Signature: ' c Q 0 _ _ . Cl �C C�n� / Date: 7--r C — to
Printed Name: NELLIE P. FILCHER
For Fifth Third Use Only
Input by: - -- - -. --
Verified by:
Revised 7/09