EX-99.B14-26-CRP1669
Xxxxxxx
& Xxxx
FINANCIAL CONSENT TO LUMP SUM DISTRIBUTION
SERVICES EXCEEDING $3,500.00
Plan Name _________________________________________________________
Participant's Name: __________________________________________________
INSTRUCTIONS: Part A or Part B must be completed.
PART A: I understand that the amount to which I am entitled from the Plan
exceeds $3,500.00. I further understand that I (and my spouse, if I am married)
must consent to the distribution being made in order to receive it, and that my
spouse's consent must be before a Notary Public or a Plan Representative.
I hereby consent to the distribution of an amount greater than $3,500.00.
Attached to this form is my Election to Waive the Joint and Survivor Annuity,
and my spouse's consent to this election.
_______________________ ____________________
Participant's Signature Date
SPOUSE'S CONSENT TO DISTRIBUTION
I hereby consent to the distribution of an amount greater than $3,500.00 to my
spouse.
________________________ ____________________
Participant's Signature Date
STATE OF ____________________)
COUNTY _____________________)
Subscribed and sworn to before me, a Notary Public in and for said County and
State, this ___________________ day of _____________________, 19___.
___________________________ My Commission Expires: _____________
Notary Public
OR
The foregoing consent was signed before me this _____ day of __________________,
19___.
__________________________________
Plan Representative and Title
PART B: STATEMENT OF UNMARRIED PARTICIPANT
( ) I am not married
_________________________ _________________
Participant's Signature Date
Marital status verified by:
_________________________ _________________
Plan Administrator Date
RETURN TO YOUR PLAN SPONSORCRP1669
