PENSION BENEFIT CLAIM

CLAIMANT INFORMATION

Participant Name: [________________________________]

Social Security Number: [____-____-____]

Date of Birth: [__/__/____]

Current Address: [________________________________]

City, State, ZIP: [________________________________]

Telephone: [________________________________]

Email: [________________________________]

EMPLOYMENT INFORMATION

Employer Name: [________________________________]

Employer Address: [________________________________]

Employee ID Number: [________________________________]

Date of Hire: [__/__/____]

Date of Termination/Retirement: [__/__/____]

Total Years of Service: [____] years [____] months

Final Position/Title: [________________________________]

Final Salary/Compensation: $[________________] per [year/month]

PENSION PLAN INFORMATION

Plan Name: [________________________________]

Plan Number: [________________________________]

Plan Administrator: [________________________________]

Plan Administrator Address: [________________________________]

Plan Administrator Phone: [________________________________]

Plan Type:
☐ Defined Benefit Plan
☐ Defined Contribution Plan (401(k), 403(b), etc.)
☐ Cash Balance Plan
☐ Multiemployer (Union) Pension Plan
☐ Other: [________________________________]

TYPE OF BENEFIT CLAIMED

☐ Normal Retirement Benefit – Attained normal retirement age under the Plan
Normal Retirement Age under Plan: [____]

☐ Early Retirement Benefit – Eligible for early retirement under Plan terms
Early Retirement Age under Plan: [____]

☐ Vested Terminated Benefit – Left employment with vested benefit
Vesting Percentage: [____]%

☐ Disability Retirement Benefit – Eligible for disability retirement
Date of Disability: [__/__/____]

☐ Survivor/Death Benefit – Claiming as beneficiary or surviving spouse
Participant's Date of Death: [__/__/____]
Relationship to Participant: [________________________________]

☐ Qualified Domestic Relations Order (QDRO) Benefit – Alternate payee under court order
QDRO Date: [__/__/____]

BENEFIT COMMENCEMENT

Requested Benefit Start Date: [__/__/____]

Form of Benefit Requested:

☐ Single Life Annuity (lifetime payments to participant only)

☐ Joint and 50% Survivor Annuity (required form for married participants unless waived)
Spouse/Beneficiary Name: [________________________________]
Spouse/Beneficiary DOB: [__/__/____]
Spouse/Beneficiary SSN: [____-____-____]

☐ Joint and 75% Survivor Annuity
Spouse/Beneficiary Name: [________________________________]
Spouse/Beneficiary DOB: [__/__/____]

☐ Joint and 100% Survivor Annuity
Spouse/Beneficiary Name: [________________________________]
Spouse/Beneficiary DOB: [__/__/____]

☐ Period Certain and Life Annuity
Period Certain: [____] years

☐ Lump Sum Distribution (if available under Plan)

☐ Other Form Available Under Plan: [________________________________]

SPOUSAL CONSENT (IF APPLICABLE)

Joint and Survivor Annuity Waiver

Under ERISA § 205, 29 U.S.C. § 1055, if you are married and elect a form of benefit other than a Qualified Joint and Survivor Annuity (QJSA), your spouse must consent to the waiver.

Participant Marital Status:
☐ Married
☐ Single
☐ Divorced
☐ Widowed

If married and waiving QJSA:

I, [Spouse Name], acknowledge that I have the right to a survivor annuity under the Plan. I understand that by consenting to the form of benefit elected above, I may give up my right to receive continuing payments after my spouse's death. I consent to the form of payment elected by the participant.

Spouse Signature: ___________________________________

Date: [__/__/____]

Witness/Notary:

___________________________________ (Signature)

[________________________________] (Name)

Notary Acknowledgment:

State of [________________]
County of [________________]

On [__/__/____], before me personally appeared [Spouse Name], known to me to be the person whose name is subscribed to the within instrument, and acknowledged that they executed the same.

___________________________________ (Notary Signature)

My Commission Expires: [__/__/____]

BENEFICIARY DESIGNATION

Primary Beneficiary:

Name: [________________________________]

Relationship: [________________________________]

Date of Birth: [__/__/____]

SSN: [____-____-____]

Address: [________________________________]

Percentage: [____]%

Contingent Beneficiary:

Name: [________________________________]

Relationship: [________________________________]

Date of Birth: [__/__/____]

SSN: [____-____-____]

Address: [________________________________]

Percentage: [____]%

BENEFIT CALCULATION INFORMATION

For Defined Benefit Plans

Service Credit Claimed:

Total Credited Service: [____] years [____] months

Final Average Compensation:

Estimated Monthly Benefit (if known): $[________________]

For Defined Contribution Plans (401(k), etc.)

Estimated Account Balance: $[________________]

As of Date: [__/__/____]

TAX WITHHOLDING ELECTION

Federal Income Tax Withholding

☐ I elect to have federal income tax withheld from my pension payments
Withholding Amount/Percentage: [________________________________]

☐ I elect NOT to have federal income tax withheld
(Note: You may still owe taxes; consult a tax advisor)

State Income Tax Withholding (if applicable)

State: [________________]

☐ Withhold state income tax
Amount/Percentage: [________________________________]

☐ Do not withhold state income tax

DIRECT DEPOSIT AUTHORIZATION

☐ I authorize direct deposit of my pension payments

Financial Institution: [________________________________]

Routing Number: [________________________________]

Account Number: [________________________________]

Account Type:
☐ Checking
☐ Savings

Please attach a voided check or bank verification letter.

ROLLOVER ELECTION (FOR LUMP SUM OR ELIGIBLE ROLLOVER DISTRIBUTIONS)

☐ Direct Rollover – Roll over distribution directly to:
☐ Traditional IRA
☐ Roth IRA (taxes due on conversion)
☐ Another employer's qualified plan

Receiving Institution: [________________________________]
Account Number: [________________________________]
Address: [________________________________]

☐ Cash Distribution – Pay distribution directly to me
(Note: 20% mandatory federal tax withholding will apply; 10% early withdrawal penalty may apply if under age 59½)

☐ Partial Rollover – Roll over $[________] and pay $[________] directly to me

SUPPORTING DOCUMENTATION CHECKLIST

☐ Copy of government-issued photo ID (driver's license, passport)
☐ Proof of date of birth (birth certificate, passport)
☐ Proof of marriage (marriage certificate, if applicable)
☐ Spouse's proof of date of birth (if electing J&S annuity)
☐ Divorce decree and QDRO (if applicable)
☐ Death certificate (if claiming survivor benefit)
☐ Proof of relationship to deceased (if claiming survivor benefit)
☐ Voided check for direct deposit
☐ IRS Form W-4P (withholding certificate)
☐ Completed beneficiary designation form
☐ Social Security Statement (optional, for verification)

PRIOR BENEFIT ELECTIONS

Have you previously received any benefits from this Plan?

☐ No

☐ Yes – Please describe: [________________________________]

Have you received a pension from a predecessor employer whose plan was merged into this Plan?

☐ No

☐ Yes – Employer Name: [________________________________]

CERTIFICATION AND SIGNATURE

I certify under penalty of perjury that:

1. The information provided in this claim is true, complete, and accurate to the best of my knowledge.

2. I understand that false statements may result in denial of benefits and potential criminal penalties.

3. I understand that the Plan has 90 days to decide my claim, with possible extensions if I am notified in writing.

4. I understand my right to appeal any adverse determination within 60 days of receiving the denial.

5. I have read and understand the spousal consent requirements if I am married and electing a form of benefit other than a Joint and Survivor Annuity.

Participant Signature: ___________________________________

Printed Name: [________________________________]

Date: [__/__/____]

SUBMISSION INSTRUCTIONS

Send this completed claim form and all supporting documentation to:

Plan Administrator: [________________________________]

Mailing Address: [________________________________]

Phone: [________________________________]

Fax: [________________________________]

Email (if accepted): [________________________________]

IMPORTANT NOTICES

Timeframes Under ERISA

• Initial Decision: The Plan must decide your claim within 90 days, which may be extended by an additional 90 days if special circumstances require and you are notified in writing.

• Appeal Deadline: If your claim is denied, you have 60 days from receipt of the denial to file an appeal.

Your Rights Under ERISA

You are entitled to:
- Examine, without charge, all plan documents at the plan administrator's office
- Obtain copies of plan documents and other plan information upon written request (a reasonable charge may apply)
- Receive a summary of the plan's annual financial report
- Receive a statement of your accrued benefits upon written request (not more than once per 12-month period)

PBGC Insurance (Defined Benefit Plans)

If this is a defined benefit pension plan, your pension benefits may be insured by the Pension Benefit Guaranty Corporation (PBGC), a federal agency. The PBGC guarantees basic pension benefits up to certain limits. Contact the PBGC at www.pbgc.gov or 1-800-400-7242 for more information.

SOURCES AND REFERENCES

• 29 U.S.C. § 1053 - Minimum Vesting Standards
• 29 U.S.C. § 1054 - Benefit Accrual Requirements
• 29 U.S.C. § 1055 - Joint and Survivor Annuity Requirements
• 29 C.F.R. § 2560.503-1 - Claims Procedure
• IRS Publication 575 - Pension and Annuity Income

This template is provided for educational and informational purposes. Seek qualified legal counsel or tax advice for specific guidance regarding your pension benefit claim.