Request To - Nationwide Retirement Solutions

One last chance to
PAY YOURSELF FIRST.
Unused accumulated leave
When you retire, your department will issue a payment to you for
the value of your unused accumulated leave, and other cashable
leave credits. Why not ‘pay yourself first’ and transfer this money
into your Savings Plus account? Talk to your personnel office
today to find out the value of your cashable leave credits.
Catch-up option
You can play “catch-up” to make up for the years you didn’t
contribute the maximum amount allowed to your 457 plan.
The catch-up provision may allow you to double your contribution
limit to the 457 plan for up to 3 consecutive years, and you may
be eligible to start as early as age 47! Use your separation pay at
retirement with catch-up to maximize your deferral!
Important Notes
• When you open a new account, your
investments are deposited into the
“Asset Allocation Index Fund Moderate”
until you request a different fund option.
Even more options for year-end retirees
• If you already have an account, your
Generally, if you separate service on or after November 1 , you may
use your separation pay + catch-up to defer into the following tax
year to maximize the benefit to your Savings Plus account.
• You can change your investment
st
selection any time online, in person, or
over the phone.
Start today
866-566-4777
or fax to 877-677-4329
sppforu.com
Mail the original form to:
cashable leave credits will deposit into
the investment choices you have on file.
or Overnight mail to:
Nationwide Retirement Solutions
P.O. Box 182797
Columbus, OH 43218-2797
Nationwide Retirement Solutions
5900 Parkwood Place
Dublin, OH 43016
• Notify your personnel office of your
decision to transfer your cashable leave
credits at least 30 days prior to your
separation date.
• If you’re approved for Catch-Up
contributions, provide a copy of your
approved Catch-Up Worksheet to your
personnel office. For more information,
review the 457 Traditional Catch-Up
booklet online, or call (866) 566-4777
to request that one be mailed to you.
Investing involves risk, including possible loss of principal.
Qualified retirement plans, deferred compensation plans and individual retirement accounts are all different, including fees and when you can access funds. Assets rolled over from
your account(s) may be subject to surrender charges, other fees and/or a 10% tax penalty if
withdrawn before age 59½. Neither Nationwide nor any of its representatives give legal or tax
advice. Please contact your legal or tax advisor for such advice.
Plan representatives are registered representatives of Nationwide Investment Services
Corporation, member FINRA.
NRM-8403CA-CA.2 (08/12)
Lump-Sum Separation Pay Transfer
Make two copies. Send the original to personnel and keep a copy for yourself (Mail or fax a copy to Savings Plus if Section ii-A is checked for enrollment).
Submit to personnel at least 30 days prior to separation.
SECTION I–Participant Information
Last Name, First Name, MI
Social Security Number (SSN)
Mailing Address
Date of Birth (mm/dd/yyyy)
City, State, ZIP Code
Separation Date (mm/dd/yyyy)
Daytime Telephone Number
(
Alternate Contact Number
)
(
)
Privacy Statement: The Information Practices Act of 1977 (Civil Code Section 1798.17) and the federal Privacy Act (Public Law 93-579) require that this notice be
provided when collecting personal information from individuals. Information requested on this form is used by Savings Plus for purposes of identification and account
processing. You must furnish all the information requested on this form. Failure to provide the information may result in the action requested not being processed.
SECTION II–Optional Enrollment Information
Complete if you need to open an account. If not, skip to Section III.
A.
Check the plan in which you wish to enroll. You may enroll in one or both plans.
401(k)
or
457
B.
(Optional) If you enroll in a new account, and you wish to contribute prior to separation, enter the amount you wish to contribute per month. The minimum
monthly contribution amount is $50. Leave blank if you don’t want to contribute prior to separation.
401(k) Contribution Amount
457 Contribution Amount
$________________
C.
Payroll warrant/check issued by (check on box only):
State Controller’s Office
CDFA/Marketing Council
California Exposition (CalExpo)
D.
$________________
District Agricultural Assoc. (Fairs)
Senate Rules Committee
Assembly Rules Committee
Legislative Analyst Office
Enter pay frequency:
Monthly
Semi-Monthly
SECTION III–Contribution Information
A.
B.
Write the amount you will have contributed to each plan for this tax year when you separate. Don’t include the lump sum separation pay you’ll contribute after you
separate.
401(k) $_____________________
403(b) $__________________________
457 $___________________________
Write the amount you plan to contribute from your lump sum separation pay below. The total amount in section A and section B cannot exceed the maximum annual
limits. Contributions to the 403(b) must be included in calculating 401(k) limits. See our website for details.
Tax Year
Year_________
Year_________
401(k)
$_______________
$_______________
457
$_________
$_________
SECTION IV–Participant Certication
I authorize Savings Plus to open an account for me according to my request as outlined in Section II of this form.
I request a contribution of lump sum separation pay in accordance with the Plan Document, Internal Revenue Code, and my election above. I take full responsibility for
providing my request to my personnel office 30 days prior to my separation date and understand the terms and conditions of deferring all or a portion of my lump sum
separation pay. If applicable, I have attached a copy of my approved Savings Plus Catch-Up Worksheet.
I understand that the State of California has the authority to approve or reject this request. I hereby certify under penalty of perjury that the information on this form is true and
accurate to the best of my knowledge.
Signature
Date
SECTION V–Personnel Ofce Use Only
Refer to SCO Personnel Letters applicable to Lump Sum Pay for instructions on completing the separation PAR. Attach this request with a copy of the separation PAR
and, if applicable, the approved Savings Plus Catch-Up Worksheet from the employee. Retain a copy with the employee file. Do not submit a copy to Savings Plus.
NRM-4074CA.10 (06/12)
State of California