Cnic Naf 401(K) Savings Plan - Termination of Employment Form

This "Cnic Naf 401(K) Savings Plan - Termination of Employment Form" is a part of the paperwork released by the U.S. Department of the Navy specifically for United States residents.

The latest fillable version of the document was released on August 1, 2012 and can be downloaded through the link below or found through the department's forms library.

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CNIC NAF 401(k) Savings Plan
Termination of Employment Form
Account Number: 51373-01-01
Activity Fund Number: ___________________
Return this form to:
Participant’s Name:
__________________________________________
NAF 401(k) Savings Plan Team
Participant’s Address:
CNIC – N941
__________________________________________
5720 Integrity Drive, Building 457
Millington TN 38055-6540
__________________________________________
Social Security Number:
__________________________________________
Participants Phone Number ____________________
LOCAL HUMAN RESOURCES OFFICE USE ONLY
(Please complete the following):
Termination Date: _____/_______/_______
Last Pay Date _____/______/______
Hours of Service worked in the plan year terminated:
 Less than 500
500-999
 1000 or Over
Send this form only after all final contribution are submitted on the Participant’s behalf. Any late deposits are subject
to the original benefit election.
DESCRIPTION OF OPTIONS
If you terminate before you are vested (employed for 1 year), you will not be eligible to receive the company Match
portion of your account balance. You will only be eligible to receive your Before-Tax Contributions.
If your vested account balance is less than $5,000, you must take a One-time Lump Sum payment either as a direct
payment to you or as a Direct Rollover to another qualified Plan or an Individual Retirement Account (IRA). There
may be an administrative fee for processing the payment or rollover deducted from your account.
Please carefully review the Participant Payee and IRA/Plan Rollover Options under the Tax Withholding Section.
TAX WITHHOLDING
Federal: Distributions, other than participant after-tax contributions, plus any earnings or losses are subject to federal
income tax withholding. Federal law requires a mandatory 20% of the taxable amount of the distribution be withheld, unless the
distribution is directly rolled over to another qualified plan or an IRA. Please read the attached Special Tax Notice for more
important information.
Contact your tax advisor or IRS if you have any questions concerning tax withholding or the Special Tax Notice.
Page 1 of 2
Revised 8/2012
CNIC NAF 401(k) Savings Plan
Termination of Employment Form
Account Number: 51373-01-01
Activity Fund Number: ___________________
Return this form to:
Participant’s Name:
__________________________________________
NAF 401(k) Savings Plan Team
Participant’s Address:
CNIC – N941
__________________________________________
5720 Integrity Drive, Building 457
Millington TN 38055-6540
__________________________________________
Social Security Number:
__________________________________________
Participants Phone Number ____________________
LOCAL HUMAN RESOURCES OFFICE USE ONLY
(Please complete the following):
Termination Date: _____/_______/_______
Last Pay Date _____/______/______
Hours of Service worked in the plan year terminated:
 Less than 500
500-999
 1000 or Over
Send this form only after all final contribution are submitted on the Participant’s behalf. Any late deposits are subject
to the original benefit election.
DESCRIPTION OF OPTIONS
If you terminate before you are vested (employed for 1 year), you will not be eligible to receive the company Match
portion of your account balance. You will only be eligible to receive your Before-Tax Contributions.
If your vested account balance is less than $5,000, you must take a One-time Lump Sum payment either as a direct
payment to you or as a Direct Rollover to another qualified Plan or an Individual Retirement Account (IRA). There
may be an administrative fee for processing the payment or rollover deducted from your account.
Please carefully review the Participant Payee and IRA/Plan Rollover Options under the Tax Withholding Section.
TAX WITHHOLDING
Federal: Distributions, other than participant after-tax contributions, plus any earnings or losses are subject to federal
income tax withholding. Federal law requires a mandatory 20% of the taxable amount of the distribution be withheld, unless the
distribution is directly rolled over to another qualified plan or an IRA. Please read the attached Special Tax Notice for more
important information.
Contact your tax advisor or IRS if you have any questions concerning tax withholding or the Special Tax Notice.
Page 1 of 2
Revised 8/2012
Termination of Employment Form
IRA/PLAN Rollover. I have read the Special Tax Notice and do not want Federal Tax of 20% withheld from my
'
payment. I elect to make direct rollover of the taxable portion of my payment to:
My new employer’s qualified plan
An IRA
'
'
Name of financial institution or new plan trustee to be listed as payee:
___________________________________________________________________________________
One-Sum Cash Payment or Rollover:
I have read The Special Tax Notice and:
 Withholding does not apply as I have already rolled over the entire taxable amount.
 Withhold the 20% mandatory federal tax withholding from the taxable portion of my payment
 Withhold the 20% mandatory federal tax withholding from the taxable portion of my payment and withhold an
additional amount of $________________.
Leave My Account Balance in the Plan. (Only available if your current account balance exceeds the Plan’s minimum
cash-out amount of $5,000).
st
[Important Note: It is your responsibility to request a distribution by the required deadline: April 1
of the year following the
year you attain normal retirement age, attain age 70 ½, or retire after attaining age 70 ½, depending on Plan provisions and
other factors. More information can be provided upon your request.]
State Tax Withholding
Residents of states without state income tax (Alaska, Florida, Nevada, South Dakota, Texas, Washington and Wyoming)
or no withholding provisions (Arkansas, Hawaii, Idaho, Louisiana, Mississippi, New Hampshire, North Carolina,
Pennsylvania, Rhode Island, Tennessee, and West Virginia) must leave this section blank.
State income tax will be withheld from the taxable portion of a payment over the state’s minimum amount if you are a resident
of Iowa, Maine, Massachusetts, Oklahoma, Vermont or Virginia. You may elect an additional amount to be withheld in Box 1.
If you are a resident of California, Georgia or Oregon, state tax is withheld unless you check Box 2. Residents of other states
can elect no state tax withholding by checking Box 2, or can select the amount of state tax to be withheld in Box 1. Obtain
additional information by contacting your state’s Department of Revenue.
Box 1.  I want $_______________________ (enter whole dollar amount) withheld from my payment for state income (or
as an additional amount for residents of IA, MA, ME, OK, VA, and VT).
Box 2.  I do no want state income tax withheld from my payment.
SIGNATURES
I understand that there may be an administrative fee deducted from my account for processing and, if all
required items are not completed on this form, that processing may be delayed.
________________________________________________
_______________________
Participant Signature
Date
________________________________________________
________________________
Plan Administrator – HQ HR Signature
Date
Page 2 of 2
Revised 8/2012
Special Tax Notice
For Payments Not From a Designated Roth Account
YOUR ROLLOVER OPTIONS
You are receiving this notice because all or a portion of a payment you are receiving from your retirement plan is
eligible to be rolled over to an IRA or an employer plan. This notice is intended to help you decide whether to do
such a rollover.
This notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth
account (a type of account with special tax rules in some employer plans). If you also receive a payment from a
designated Roth account in the Plan, you will be provided a different notice for that payment, and the Plan
administrator or the payor will tell you the amount that is being paid from each account.
Rules that apply to most payments from a plan are described in the "General Information About Rollovers"
section. Special rules that only apply in certain circumstances are described in the "Special Rules and Options"
section.
GENERAL INFORMATION ABOUT ROLLOVERS
How can a rollover affect my taxes?
You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59 1/2 and do not do
a rollover, you will also have to pay a 10% additional income tax on early distributions (unless an exception
applies). However, if you do a rollover, you will not have to pay tax until you receive payments later and the 10%
additional income tax will not apply if those payments are made after you are age 59 1/2 (or if an exception
applies).
Where may I roll over the payment?
You may roll over the payment to either an IRA (an individual retirement account or individual retirement
annuity) or an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457(b) plan) that
will accept the rollover. The rules of the IRA or employer plan that holds the rollover will determine your
investment options, fees, and rights to payment from the IRA or employer plan (for example, no spousal consent
rules apply to IRAs and IRAs may not provide loans). Further, the amount rolled over will become subject to the
tax rules that apply to the IRA or employer plan.
How do I do a rollover?
There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover.
If you do a direct rollover, the Plan will make the payment directly to your IRA or an employer plan. You should
contact the IRA sponsor or the administrator of the employer plan for information on how to do a direct rollover.
If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible employer
plan that will accept it. You will have 60 days after you receive the payment to make the deposit. If you do not do
a direct rollover, the Plan is required to withhold 20% of the payment for federal income taxes (up to the amount
of cash and property received other than employer stock). This means that, in order to roll over the entire
payment in a 60-day rollover, you must use other funds to make up for the 20% withheld. If you do not roll over
the entire amount of the payment, the portion not rolled over will be taxed and will be subject to the 10%
additional income tax on early distributions if you are under age 59 1/2 (unless an exception applies).
How much may I roll over?
If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the
Plan is eligible for rollover, except:
y Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the
lives or joint life expectancy of you and your beneficiary)
y Required minimum distributions after age 70 1/2 (or after death)
y Hardship distributions
y ESOP dividends
y Corrective distributions of contributions that exceed tax law limitations
y Loans treated as deemed distributions (for example, loans in default due to missed payments before your
employment ends)
y Cost of life insurance paid by the Plan
y Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request
within 90 days of enrollment
y Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP
(also, there will generally be adverse tax consequences if you roll over a distribution of S corporation
stock to an IRA).
The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.
If I don't do a rollover, will I have to pay the 10% additional income tax on early distributions?
If you are under age 59 1/2, you will have to pay the 10% additional income tax on early distributions for any
payment from the Plan (including amounts withheld for income tax) that you do not roll over, unless one of the
exceptions listed below applies. This tax is in addition to the regular income tax on the payment not rolled over.
The 10% additional income tax does not apply to the following payments from the Plan:
y Payments made after you separate from service if you will be at least age 55 in the year of the separation
y Payments that start after you separate from service if paid at least annually in equal or close to equal
amounts over your life or life expectancy (or the lives or joint life expectancy of you and your
beneficiary)
y Payments from a governmental defined benefit pension plan made after you separate from service if you
are a public safety employee and you are at least age 50 in the year of the separation
y Payments made due to disability
y Payments after your death
y Payments of ESOP dividends
y Corrective distributions of contributions that exceed tax law limitations
y Cost of life insurance paid by the Plan
y Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request
within 90 days of enrollment
y Payments made directly to the government to satisfy a federal tax levy
y Payments made under a qualified domestic relations order (QDRO)
y Payments up to the amount of your deductible medical expenses
y Certain payments made while you are on active duty if you were a member of a reserve component
called to duty after September 11, 2001 for more than 179 days
y Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the
first contribution.
If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from the IRA?
If you receive a payment from an IRA when you are under age 59 1/2, you will have to pay the 10% additional
income tax on early distributions from the IRA, unless an exception applies. In general, the exceptions to the
10% additional income tax for early distributions from an IRA are the same as the exceptions listed above for
early distributions from a plan. However, there are a few differences for payments from an IRA, including:
y There is no exception for payments after separation from service that are made after age 55.
y The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule
applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made
directly to an IRA of a spouse or former spouse).
y The exception for payments made at least annually in equal or close to equal amounts over a specified
period applies without regard to whether you have had a separation from service.
y There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments
up to $10,000 used in a qualified first-time home purchase, and (3) payments after you have received
unemployment compensation for 12 consecutive weeks (or would have been eligible to receive
unemployment compensation but for self-employed status).
Will I owe State income taxes?
This notice does not describe any State or local income tax rules (including withholding rules).
SPECIAL RULES AND OPTIONS
If your payment includes after-tax contributions
After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable
portion of your after-tax contributions is generally included in the payment. If you have pre-1987 after-tax
contributions maintained in a separate account, a special rule may apply to determine whether the after-tax
contributions are included in a payment.
You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a
60-day rollover. You must keep track of the aggregate amount of the after-tax contributions in all of your IRAs (in
order to determine your taxable income for later payments from the IRAs). If you do a direct rollover of only a
portion of the amount paid from the Plan and a portion is paid to you, you can decide whether you want to
rollover your after tax portion or have it paid directly to you as a cash distribution. If you do a 60-day rollover to
an IRA of only a portion of the payment made to you, the after-tax contributions are treated as rolled over last.
For example, assume you are receiving a complete distribution of your benefit which totals $12,000, of which
$2,000 is after-tax contributions. In this case, if you roll over $10,000 to an IRA in a 60-day rollover, no amount
is taxable because the $2,000 amount not rolled over is treated as being after-tax contributions.
You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a
direct rollover (and only if the receiving plan separately accounts for after-tax contributions and is not a
governmental section 457(b) plan). You can do a 60-day rollover to an employer plan of part of a payment that
includes after-tax contributions, but only up to the amount of the payment that would be taxable if not rolled
over.

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