City Beverages Enrollment - Web Book - Ready - Flipbook - Page 23
Transfer or Direct Rollover Request
Return completed form to:
Certified Benefits Corp, 1111 Douglas Avenue, Altamonte Springs, FL 32714
1.
Participant Information
Name
Telephone Number
Address
Social Security Number
City
State
Zip
Name of Present Employer
Date of Birth
Date of Hire
Type of Account Established at Certified Benefits Corp:
2.
401(k)
403(b)
Account to be Transferred
I authorize my present Custodian/Trustee of my IRA, or my present employer of my retirement plan, to send the assets indicated in Part 3 below directly
to my account with Certified Benefits Corp, Third Party Administrator (TPA).
Name of Present Custodian or Trustee
Address
City
Phone Number
Current Account Number(s)
Type of Account Being Transferred:
3.
401(k)
State
403(b)
457
Zip
Traditional IRA
Payment Information and Instructions
Please attach a copy of your most recent statement from the account you wish to transfer or rollover.
I authorize and direct my present Custodian/Trustee to send my assets as follows:
Immediately liquidate all assets and send the cash proceeds
Partial Distribution of $_____________(transfer or rollover amount)
Attached is my rollover contribution check in the amount of: $________________.
Make check payable to “City Beverages 401(k) Plan” FBO (account holder’s name)”
Mail proceeds to:
4.
Certified Benefits Corp
1111 Douglas Avenue
Altamonte Springs, FL 32714
Signature and Certification
I certify that I have established an account with Certified Benefits Corp (TPA), for which Fidelity Investments NFS Corp. is the Custodian. I understand
that I am responsible for determining my eligibility for all transfers or rollovers. I agree to hold the TPA and Custodian harmless against any and all
situations arising from an ineligible transfer or direct rollover. I acknowledge that the TPA and Custodian cannot provide legal advice, and I agree to
consult with my own tax professional for advice.
Participant Signature
Date
Employer Authorization
Date
Certified Benefits Corp is an affiliate of Certified Financial Group, Inc.
Planning Tomorrow….Today! is a registered federal trademark of Certified Financial Group, Inc.
