Diocese Enrollment - Web Book - Ready - Flipbook - Page 23
DIOCESE OF ORLANDO EMPLOYEE 403(b) SAVINGS & RETIREMENT PLAN
ROLLOVER CONTRIBUTION/TRANSFER FORM
Please complete the following accurately with a pen; print clearly. The information you provide should be current as of the
date the form is completed.
SECTION I – General Information
Last Name
First Name
MI
Social Security Number
_______
Mailing Address
Residence Telephone
_____________________
City
State
Diocesan Entity Name: (Parish, School, etc.)
Zip
Email
City
Work Telephone
SECTION II - Rollover Contribution/Transfer
I understand the Diocese of Orlando Employee 403(b) Savings & Retirement Plan accepts pre-tax qualifying
rollovers/transfers on behalf of Employees for distributions from:
(1)
Another 403(b) plan (pre-tax funds only)
(2)
An Individual Retirement Account (pre-tax funds only), or
(3)
A qualified retirement plan (i.e. 401(k), 457, profit sharing or pension plan)(pre-tax funds only)
All rollover contributions/transfers MUST BE MADE PAYABLE TO Diocese of Orlando Employee 403(b) Savings &
Retirement Plan FBO (your name) and deposited no later than the 60th day if you received the distribution. If you are
initiating a transfer from another eligible plan, you should contact a representative from the plan you are transferring from as
they may have specific forms to authorize your transfer. Please deliver all rollover contributions/transfers accompanied with
a completed Rollover Contribution/Transfer Form to: Certified Benefits Corp, 1111 Douglas Avenue, Altamonte Springs, FL
32714. I also realize I may be required to provide additional information before the final determination can be made. I
understand the rollover contribution/transfer must not include any nondeductible (after-tax) Employee contributions.
This rollover/transfer is from:
another 403(b) plan,
or
an IRA,
or
a qualified plan
Attached is my rollover contribution check in the amount of: $________________, or
Rollover contribution check will be mailed to Certified Benefits Corp from my IRA or qualified plan, or
I request the assistance of Certified Benefits Corp with the transfer/rollover of my vested benefit from the account
list below; please immediately liquidate all assets and send the cash proceeds.
Company Name *
Plan Name
Company Address
City
Plan Contact Name
State
Zip
Contact Telephone Number
* Please attach copy of most recent statement from this company if requesting the assistance of CBC.
SECTION III - Signature – Review to make sure that you have completed each section.
Employee Signature: ______________________________________________ Date: _________________________
Employer Authorization: ___________________________________________ Date: _________________________
Certified Benefits Corp (407) 869-9800
(800) 393-9900
8/11/2016