Fill Out Your Lincoln Request Distribution Form

Is this the correct form?

This form can be used for the most common distribution reasons. This will result in a payment to another company.

If you would like to request a distribution for another reason, please refer to the

Moving your money to another company can be a big decision.

Understanding whether your rollover, transfer, or exchange of assets is permissible under current regulations will help you to limit any tax consequences. To get you started, we have provided a general summary of the different methods to move your money. For additional information, please consult with a tax advisor and/or go to the IRS website, https://www.irs.gov.

Lincoln website for the applicable form. DO NOT use this form for:

•Hardship or Unforeseeable emergency

•Required minimum distribution (RMD)

•Excess withdrawal (refund)

•Death claim (you are the beneficiary)

•Plan termination

•In-plan Roth conversion

Need additional help?

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LincolnFinancial.com or

CALL

1-800-234-3500,

M - F, 8 am - 8 pm ET

Methods to move your money

Rollover

A rollover is the movement of assets between two different retirement plans. You can elect a rollover if you:

yy Are no longer employed with the employer administering this plan.

yy Are retired.

yy Meet the age requirements for an in- service withdrawal. (Check with your plan administrator/employer for age restrictions.)

yy Are totally and permanently disabled.

yy Are an alternate payee due to a Qualified Domestic Relations Order.

For example: You could move assets from an existing retirement account that is from a former employer to your retirement account with your current employer or to an IRA.

Refer to the Special Tax Notice for more information about what types of transactions are eligible for rollover.

Please note: If you are required to take a minimum distribution for this calendar year, your annual RMD must be satisfied before a rollover can be processed. If you elect a rollover, we will automatically distribute any outstanding RMD, withhold taxes, and mail a check to your address on record. If you would like more options for RMD withdrawal, please complete the RMD form, available on the Lincoln web site, before electing a rollover.

Contract exchange

A contract exchange is only available to 403(b) plans. It is a tax-free transfer of one 403(b) account to another 403(b) account within the same 403(b) retirement plan. No reason for distribution is necessary, but an exchange must be permitted by the plan.

(A contract exchange may not be available in your plan. Please contact your plan administrator/employer to see if

this option is available.)

For example: Your employer offers multiple retirement plan providers and you may transfer assets from one 403(b) provider to another.

Plan-to-plan transfer

A plan-to plan transfer is a transfer of assets from one retirement plan to another retirement plan. You can elect a plan-to-plan transfer if:

yy The transfer is between the same plan type (such as 403(b) plan to 403(b) plan).

yy Both plans allow for the transfer.

Please note: This type of transfer is usually used when you are not eligible for a distribution/rollover but wish to consolidate your retirement assets within a single plan.

For example:

You are working for an employer that is part of a group of employers. Each employer sponsors their own 403(b) plan. (IE: a group of hospitals, each has their own retirement plan) You transfer employment from one employer to another employer within this group.

(IE: move from one hospital to another within the same organization) You are not eligible for a distribution/ rollover, but you would like all of your retirement assets in one plan. If both employers’ plans permit the transfer, this would allow you to consolidate your retirement assets.

(A plan-to-plan transfer may not be available to your plan. Please contact your plan administrator/employer to see if

this option is available.)

Permissive service credit transfer

A permissive service credit transfer is a type of plan-to-plan transfer used to purchase additional service in a government defined benefit plan.

You may be eligible to transfer money from your current retirement plan to a government defined benefit plan. This money would be used to purchase additional service or benefits under that plan. No reason for distribution is necessary.

(Transfer to purchase service credits may not be available to your plan. Please contact your plan administrator/employer to see if this option is available.)

Is this the correct form?

This form can be used for the most common distribution reasons. This will result in a payment to another company.

If you would like to request a distribution for another reason, please refer to the Lincoln website for the applicable form.

DO NOT use this form for:

1Tell us about yourself.

Marital status: Please provide your martial status in order to ensure timely

processing of your distribution.

Marital status

 I do not have a living spouse.  I have a living spouse.

Employment status (choose one)

 I retired on (mm/dd/yyyy)

/

/

.

Date of birth (mm/dd/yyyy)

Restrictions may apply depending on your plan provisions. Please contact

your plan administrator/employer to discuss what options are available.

If you are totally and permanently disabled: A letter from the Social Security Administration is required.

For Qualified Domestic Relations Orders: A copy of the court order, divorce, or legal separation is required.

If you have Roth and/or after tax money, please verify that your receiving

company will accept your rollover.

When requesting a rollover of pre-tax money to a Roth IRA you will still be liable

for payment of federal and state income tax, if applicable, at the time you prepare your personal tax filing. You may wish to discuss your personal tax liability with a qualified tax advisor.

Receiving company information: If your receiving company information is incomplete or inaccurate, we will issue the check to the receiving company but mail it to your address. You will be responsible for mailing the check to the receiving company to complete the transaction.

 I am no longer working for the employer that administers this plan as of​

 I am currently employed with the employer that administers this plan. (Restrictions may apply.)   I am totally and permanently disabled. 

 I am not an employee. (You are the alternate payee due to a Qualified Domestic Relations Order.) 

2How should we move your funds to another company?

Please refer to “Requesting a distribution to another company” included with this form.

I would like to distribute my money in the form of a (choose one)

 Rollover

If you have after tax contributions and you elect a rollover, Lincoln will automatically include your after tax contributions unless you tell us otherwise by checking this box:  Do not include my after tax contributions in this rollover. 

 Contract exchange (Restrictions may apply.)   Plan-to-plan transfer (Restrictions may apply.) 

 Permissive service credit transfer (Restrictions may apply.) 

Type of receiving plan/account (choose one)

 401(k)   403(b)   401(a)   457(b) governmental

 Individual Retirement Account (IRA) (Traditional, SEP, SIMPLE, etc.)

 Roth IRA    Defined benefit plan

Restrictions may apply to options (where noted) on this form depending on your plan.

Please contact your plan administrator/ employer to discuss what options are available.

Amount options (choose one)

 Send 100% of my account balance to another If applicable, your distribution will automatically include the

provided. Skip to Step 6.) (Restrictions may apply.) 

Direct Deposit: If your bank account information is illegible or incomplete,

Lincoln will issue a check and mail to your address on file.

Please note: We cannot direct deposit to reloadable bank cards.

If you direct deposit to a checking account: A voided

check or a verification of deposit from your financial institution is required.

If you direct deposit to a savings account: A verification of deposit from your financial institution is required.

The amount you receive:

The total amount you receive from this distribution will be reduced by the total amount of taxes withheld. Depending on your available balance, you may adjust your requested distribution amount to account for additional taxes that may be assessed as part of your tax liability.

Federal tax withholding election: If you do not provide a rate, or if you

provide a federal tax withholding rate that is less than 20%, we are still required to withhold the applicable minimum.

Please note: Your distribution may be subject to an additional 10% early distribution penalty tax. This penalty tax will be assessed when you file your tax returns as part of your tax liability and is not automatically included in your tax withholding for this distribution.

PAD-2185169-071918

RPS92618-AL-T (7/18)

 Send me a partial cash payment of

$and send the remainder of my account balance to another company as described in Step 2. (Dollar amount must be

provided. Continue to Step 4.)

4How would you like to receive your payment?

Only complete this section if you are receiving a partial cash payment.

I would like my payment to be sent as a (choose one)

 Direct deposit to my personal bank account as described here:

Type of account:   Checking    Savings

 Check, mailed to my address on file. 

5How do taxes impact your partial cash payment?

Only complete this section if you are receiving a partial cash payment.

Lincoln will withhold taxes from your distribution at the rates detailed below and automatically send the withholding to the IRS on your behalf. Please refer to the Special Tax Notice for more information.

Taxes withheld from your distribution will include:

yy Federal tax (if applicable) 

20% mandatory withholding applies to distributions that are eligible for rollover.

Indicate here if you would like to withhold federal taxes at a higher rate than the mandatory 20%:

Did you know?

If you move this year: Please update your address to receive your tax documents for use when you file your income taxes.

To update your address: If you are an active employee, contact your employer; if you are no longer employed, call Lincoln.

6Sign and date this form.

For New York residents only: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

By signing below, I certify that:

yy I have read and understand the Important Fraud Notice and Important Information sections on the last page of this form.

yy I have received the Special Tax Notice, and if applicable, I waive the required 30-day notice period before receiving my distribution.

yy I am responsible for meeting the federal tax law requirements to qualify for this distribution. yy My answers on this form and any documents I have attached are true and accurate.

yy If there are not enough funds in my retirement account for the amount requested, Lincoln will process the withdrawal from the amount available.

yy If applicable to this plan, I have received the Qualified Joint and Survivor Annuity (QJSA) notice; waive the 30 day review period and normal QJSA form of payment; and instead; elect to receive this distribution as detailed on this form.

/

/

If spousal consent is required and if your plan administrator does not sign

here as a witness to your spouse’s signature, you must have a notary sign, seal, and date where noted to the right.

7Your spouse’s signature may be required.

In some instances, your spouse may be required to sign this form. Please call your plan administrator/ employer to determine if this is required for your plan. This section is not needed for distributions due to Qualified Domestic Relations Order.

By signing below, I certify that I am the spouse of the individual named above and that:

yy If applicable to this plan, I have received the QJSA notice, consent to my spouse’s election to waive the normal QJSA form of payment, and consent to my spouse’s election to an immediate distribution as detailed on this form.

Did you remember to:

Print, sign and date this form?

Attach any necessary documents?

If faxing, include both the front and back of ALL pages of the form?

Questions?

VISIT

LincolnFinancial.com or

CALL

1-800-234-3500,

M - F, 8 am - 8 pm ET

Current, former, or non-employee - return all documents to:

Your employer’s Human Resources department.

What you can expect:

yy Log in to your account at LincolnFinancial.com to verify when funds are removed from your retirement account.

yy For ACH deposits, it takes up to two business days to see your payment posted to your bank account once the funds have left your retirement account.

yy For checks, your payment will arrive depending on the United States Postal Service delivery schedule. This generally takes 2-5 business days once the funds have left your retirement account.

/

/

Participant information: If participant information is incomplete, Lincoln

will use the information currently on file.

Authorization: Lincoln will process this request based on TPA authorization only. Lincoln will not screen for plan administrator/ employer’s signature or QDRO orders.

TPA distribution fees are established at plan setup, deducted automatically at the time of withdrawal, and included in the aggregated monthly fee sent to the TPA. For recurring distribution payments, the fee will be assessed only for the initial withdrawal.

Plan administrator or TPA return all documents to:

•FAX

Lincoln Retirement Services Company, LLC 260-455-9975

•MAIL

Lincoln Retirement Services Company, LLC

P.O. Box 7876

Fort Wayne, IN 46801-7876

•EXPRESS MAIL

Lincoln Retirement Services Company, LLC

1300 South Clinton St. Fort Wayne, IN 46802-3506

IMPORTANT INFORMATION

There are restrictions on the amount that can be withdrawn from the Lincoln Fixed Account/Lincoln Stable Value Account/ Lincoln Stable Value Separate Account in a 12-month period. Transfers from the Lincoln Stable Value Account/Lincoln Stable Value Separate Account may be subject to a 90-day equity wash.

Lincoln Financial Group® affiliates, their distributors, and their respective employees, representatives, and/or insurance agents do not provide tax, accounting, or legal advice. Clients should consult their own independent advisor as to any tax, accounting or legal statements made herein. We recommend that you consult a tax advisor regarding the distribution rules as they pertain to your personal circumstances.

Third party administrator (TPA) use only. 

Complete the following information:

yy If the employee is no longer working, provide the date of severance​

IMPORTANT FRAUD NOTICE

Residents of all states except Alabama, Arkansas, Colorado, District of Columbia, Florida, Kentucky, Louisiana, Maine, Maryland, New Jersey, New Mexico, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Vermont, Virginia and Washington, please note: Any person who knowingly, and with intent to defraud any insurance company or other person, files or submits an application or statement of claim containing any materially false or deceptive information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and may subject such person to criminal and civil penalties.

For Arkansas, Colorado, Kentucky, Maine, New Mexico, Ohio, Rhode Island, Tennessee residents only: Any person who, knowingly and with intent to injure, defraud or deceive any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and may subject such person to criminal and civil penalties, fines, imprisonment, or a denial of insurance benefits.

For Alabama and Louisiana residents only: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

For District of Columbia residents only: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

For Florida and New Jersey residents only: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

For Maryland residents only: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

For Oklahoma and Pennsylvania residents only: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

For Vermont residents only: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

For Washington residents only: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

Your rollover options

You are receiving this notice because all or a portion of a payment you are receiving from an employer-sponsored retirement plan (“Plan”) may be eligible to be rolled over to an IRA, an employer plan, or Roth IRA. This notice is intended to help you decide whether to do such a rollover.

This notice describes the rollover rules that apply to payments that are from a “designated Roth account” (an account for after-tax, Roth elective deferral contributions) and payments from a “non-Roth account” (an account for pre-tax elective deferral contributions). If you are only receiving a payment from one of these types of accounts, you need only read the sections of this notice that apply to that type of account. If you are receiving payments from both types of accounts, you should read the entire notice. In addition, the Plan administrator or payor will tell you the amount that is being paid from each account if you are receiving payments from both types of accounts.

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?

Non-Roth account

You will be taxed on a payment from a non-Roth account under the Plan if you do not roll it over. If you are under age 59½ 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 ½ (or if an exception applies).

Designated Roth account

After-tax contributions included in a payment from a designated Roth account are not taxed, but earnings might be taxed. The tax treatment of earnings included in the payment depends on whether the payment is a qualified distribution. If a payment is only part of your designated Roth account, the payment will include an allocable portion of the earnings in your designated Roth account.

If the payment from the Plan is not a qualified distribution and you do not do a rollover to a Roth IRA or a designated Roth account in an employer plan, you will be taxed on the earnings in the payment. If you are under age 59½, a 10% additional income tax on the early distributions will also apply to the earnings (unless an exception applies). However, if you do a rollover, you will not have to pay taxes currently on the earnings and you will not have to pay taxes later on payments that are qualified distributions.

If the payment from the Plan is a qualified distribution, you will not be taxed on any part of the payment even if you do not do a rollover. If you do a rollover, you will not be taxed on the amount you roll over and any earnings on the amount you roll over will not be taxed if paid later in a qualified distribution.

A qualified distribution from a designated Roth account in the Plan is a payment made after you are age 59½ (or after your death or disability) and after you have had a designated Roth account in the Plan for at least 5 years. In applying the 5-year rule, you count from January 1 of the year your first contribution was made to the designated Roth account. However, if you did a direct rollover to a designated Roth account in the Plan from a designated Roth account in another employer plan, your participation will count from January 1 of the year your first contribution was made to the designated Roth account in the Plan or, if earlier, to the designated Roth account in the other employer plan.

What types of retirement accounts and plans may accept my rollover?

Non-Roth account

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.

Designated Roth account

You may roll over the payment from a designated Roth account to either a Roth IRA (a Roth individual retirement account or Roth individual retirement annuity) or a designated Roth account in an employer plan (a tax-qualified plan, section 403(b) plan or governmental 457(b) plan) that will accept the rollover. The rules of the Roth IRA or employer plan that holds the rollover will determine your investment options, fees, and rights to payment from the Roth IRA or employer plan (for example, no spousal consent rules apply to Roth IRAs and Roth IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the Roth IRA or the designated Roth account in the employer plan. In general, these tax rules are similar to those described elsewhere in this notice, but differences include:

yy If you do a rollover to a Roth IRA, all of your Roth IRAs will be considered for purposes of determining whether you have satisfied the 5-year rule (counting from January 1 of the year for which your first contribution was made to any of your Roth IRAs). yy If you do a rollover to a Roth IRA, you will not be required to take a distribution from the Roth IRA during your lifetime and you must keep track of the aggregate amount of the after-tax contributions in all of your Roth IRAs (in order to determine your taxable income

for later Roth IRA payments that are not qualified distributions). yy Eligible rollover distributions from a Roth IRA can only be rolled

over to another Roth IRA.

How do I do a rollover?

There are two ways to do a rollover. You can either do a direct rollover or a 60-day rollover.

Non-Roth account

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. Generally, 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 59½ (unless an exception applies).

yy Corrective distributions of contributions that exceed tax law limitations

yy Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends)

yy Cost of life insurance paid by the Plan

yy Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution

yy 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.

Designated Roth account

If you do a direct rollover, the Plan will make the payment directly to your Roth IRA or designated Roth account in an employer plan. You should contact the Roth 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 (generally within 60 days) into a Roth IRA, whether the payment is a qualified or nonqualified distribution. In addition, you can do a rollover by making a deposit within 60 days into a designated Roth account in an employer plan if the payment is a nonqualified distribution and the rollover does not exceed the amount of the earnings in the payment. You cannot do a 60-day rollover to an employer plan of any part of a qualified distribution. If you receive a distribution that is a nonqualified distribution and you do not roll over an amount at least equal to the earnings allocable to the distribution, you will be taxed on the amount of those earnings not rolled over, including the 10% additional income tax on early distributions if you are under age 59½ (unless an exception applies).

If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you at the same time, the portion directly rolled over consists first of earnings.

If you do not do a direct rollover and the payment is not a qualified distribution, the Plan is required to withhold 20% of the earnings 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 to a Roth IRA, you must use other funds to make up for the 20% withheld.

How much may I roll over?

The following rules are the same for both non-Roth and designated Roth accounts.

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:

yy 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)

yy Required minimum distributions after age 70½ (or after death) yy Hardship distributions

yy ESOP dividends

If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions?

Non-Roth account

If you are under age 59½, 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 applies to the part of the distribution that you must include in income and is in addition to the regular income tax on the payment not rolled over.

Designated Roth account

If the payment is not a qualified distribution and you are under age 59½, you will have to pay the 10% additional income tax on early distributions with respect to the earnings allocated to the payment that you do not roll over (including amounts withheld for income tax), unless one of the exceptions listed below applies. This tax is in addition to the regular income tax on the earnings not rolled over.

Both Non-Roth accounts and designated Roth accounts

The 10% additional income tax does not apply to the following payments from the Plan:

yy Payments made after you separate from service if you will be at least age 55 in the year of the separation

yy 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)

yy Payments from a governmental retirement plan made after you separate from service if you are a qualified public safety employee and you will be at least age 50 in the year of the separation. The term “qualified public safety employee” means public safety employees of a state, political subdivision of a state; and specified federal law enforcement officers, federal customs and border protection officers, federal firefighters and air traffic controllers

yy Payments made due to disability yy Payments after your death

yy Payments of ESOP dividends

yy Corrective distributions of contributions that exceed tax law limitations

yy Cost of life insurance paid by the Plan

yy Payments made directly to the government to satisfy a federal tax levy