MIME-Version: 1.0 Content-Location: file:///C:/9E74CAAD/After-TaxContributionsPortionofEligibleRolloverDistributionElectionForm.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" GENESEE COUNTY EMPLOYEES’ RETIREMENT SYSTEM

GE= NESEE COUNTY EMPLOYEES’ RETIREMENT SYSTEM

AFTER-TAX CONTRIBUTIONS PORTION OF ELIGIBLE ROLLOVER DISTRIBUTION ELECTION FORM

To be completed by distribution recipient with regard to the $_______________ (fill in amount) = after-tax contributions portion of the distribution to be received.

Please select option A, B or C below:

A.        &= nbsp;  The Genesee County Employees’ Retirement System is directed to make full payment of my after-tax contributions to me, the member or beneficiary.

______________________________________        = ;            &n= bsp;        

________________________________________

Signature  &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;               = ;            &n= bsp;        

Date

  =

B.        &= nbsp;  The Genesee County Employees’ Retirement System is directed to deliver my after-tax contributions to ________________________________________, Truste= e, for deposit in accordance with the rollover provisions. <= o:p>

______________________________________        = ;            &n= bsp;        

________________________________________

Signature  &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;               = ;            &n= bsp;        

Date

  =

C.        &= nbsp;  The Genesee County Employees’ Retirement System is directed to deliver $_______________ (fill in amount) of my after-tax contributions to ________________________________________, Trustee, for deposit in accordance with the rollover provisions.  The remainder of my after-tax contributions will be paid directly to me, the me= mber or beneficiary.

______________________________________        = ;            &n= bsp;        

________________________________________

Signature  &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;               = ;            &n= bsp;        

Date

 

Complete Agreement of Depository Trustee below if option B or C is selected. <= /span>

To be completed by Trustee of eligible employer plan or traditional IRA.=

AGREEMENT OF DEPOSITORY TRUSTEE <= /o:p>

In accordance with the above authorization of the depositor, we agree to depos= it the forthcoming rollover amount from the Genesee County Employees’ Retirement System in the following account:

Type = of Account (check one):

1) 408(a)_______

2) 408(b)_______

   &nbs= p;           3) 401(a)_______    &nbs= p;

4) 403(a)_______

   &nbs= p;           5) 403(b)_______

________________________________________        = ;            &n= bsp;            = ;            =

________________________________________        = ;            &n= bsp;            = ;            =

Name of Trustee &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;                 = ;            &n= bsp;            = ;            &n= bsp;            = ; 

Authorized Signature

________________________________________        = ;            &n= bsp;            = ;            =

________________________________________        = ;            &n= bsp;            = ;            =

Mailing Address &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;                  = ;            &n= bsp;            = ;            &n= bsp;            = ; 

Date

________________________________________        = ;            &n= bsp;            = ;            =

(_______)_______________________________        = ;            &n= bsp;            = ;            =

City   =             &nb= sp;            =            State        = ;            &n= bsp; Zip        = ;            &n= bsp;            = ;            &n= bsp;            = ; 

   &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;      Telephone

 

Return to:

Retirement Office Supervisor

 

G= enesee <= st1:PlaceType w:st=3D"on">County Employees’ Retirement System

 

= 1= 101 Beach Street

 

F= lint, = Michigan 48502-1453<= /st1:PostalCode>

 

(810) 257-2626 or (800) 949-2627=

 <= /o:p>