To: Retirement
Office Supervisor
I have received the Special Tax
Notice Regarding Plan Payments, which explains the tax consequences of, and the
direct rollover option available with respect to, my distribution from the
Genesee County Employees’ Retirement System.
I understand that I have the right to consider the information provided
in the Special Tax Notice Regarding Plan Payments for at least 30 days.
To the extent that my distribution
from the Genesee County Employees’ Retirement System can be made, or begin to
be made, before the close of the 30 day period beginning with the date I
received the Special Tax Notice Regarding Plan Payments, I hereby waive my
right to consider the contents of that notice for the full 30 day period, and I
hereby consent to the making of my distribution from the Plan as soon as
administratively feasible.
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Date |
_____________________________________________________ |
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Signature
of Distributee |
_____________________________________________________ |
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Full Name
(please print)) |
_____________________________________________________ |
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Social
Security Number |
_____________________________________________________ |
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Employer |
_____________________________________________________ |
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Return
to: |
Retirement Office Supervisor |
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(810) 257-2626 or (800) 949-2627 |