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VL 19552 - 65886001

The document is a Mutual Fund Distribution Request Form for the Valley Health Corporation 403(b) Plan, detailing client information, distribution methods, and tax withholding instructions. It outlines options for withdrawal, surrender, installments, or annuity, along with the necessary spousal consent and administrator approval sections. Additionally, it includes information about the Qualified Joint and Survivor Annuity and other distribution benefits under ERISA plans.
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© © All Rights Reserved
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0% found this document useful (0 votes)
57 views9 pages

VL 19552 - 65886001

The document is a Mutual Fund Distribution Request Form for the Valley Health Corporation 403(b) Plan, detailing client information, distribution methods, and tax withholding instructions. It outlines options for withdrawal, surrender, installments, or annuity, along with the necessary spousal consent and administrator approval sections. Additionally, it includes information about the Qualified Joint and Survivor Annuity and other distribution benefits under ERISA plans.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 9

Northeast

[Enter GroupValley Health Corporation 403(b) Plan


Name Here]
Mutual Fund Distribution Request Form
Group ID# [000000000]
VALIC Retirement Services Company (VRSCO)
Group ID # 65886001
1. CLIENT INFORMATION
Gloria Matta
Name: ____________________________________________________________________________ 048523889
SSN or Tax ID: ___________________________

747- 999-7826
Daytime Phone: (_______)_________________________________ 12/13/1958
Date of Birth: ________________________________

2. DISTRIBUTION METHOD
Choose from one of the following distribution methods below. Please review the enclosed “SPECIAL TAX NOTICE” carefully.

OPTION A → WITHDRAWAL
• Distributes funds as requested and leaves account open
• Future contributions accepted if allowed by the plan
• No impact to outstanding loans
Please indicate Account(s) you wish to withdraw from.
500c155
Account #______________________________ Account #______________________________ Account #______________________________
$__75,000
________________ or_______________ % $__________________ or_______________ % $__________________ or_______________ %
Choose one: Choose one: Choose one:
l Distribute the amount pro-rata against l Distribute the amount pro-rata against l Distribute the amount pro-rata against
all available funds excluding Schwab all available funds excluding Schwab all available funds excluding Schwab
PCRA (default) PCRA (default) PCRA (default)
l Distribute the amount pro-rata against all l Distribute the amount pro-rata against all l Distribute the amount pro-rata against all
available funds including Schwab PCRA available funds including Schwab PCRA available funds including Schwab PCRA
l Distribute the amount or percentage from l Distribute the amount or percentage from l Distribute the amount or percentage from
each fund as specified below: each fund as specified below: each fund as specified below:
Fund Code Amount Fund Code Amount Fund Code Amount

___________ $___________ or __________ % ___________ $___________ or __________ % ___________ $___________ or __________ %

___________ $___________ or __________ % ___________ $___________ or __________ % ___________ $___________ or __________ %

___________ $___________ or __________ % ___________ $___________ or __________ % ___________ $___________ or __________ %

OPTION B → SURRENDER
• Automatically closes the account
• Future contributions will not be accepted
• Any active outstanding loan(s) will be terminated and reported as taxable distribution(s)
Please indicate Account(s) you wish to surrender.

Account # ________________________________ Account # ______________________________ Account # _______________________________

OPTION C → INSTALLMENTS (Please complete a Mutual Fund Systematic Withdrawal Form.)

OPTION D → ANNUITY IF AVAILABLE UNDER THE PLAN (Please complete VALIC’s Annuity Benefits Form.)

3. DISTRIBUTION REASON 403(a)/(b), 401(a)/(k) or 457(b) Deferred Compensation* Plan Participants:


l Separation from Service as of 08-22-2022
________________ (date) due to l Termination l Early Retirement l Normal Retirement
Did you separate from service during or after the year you attained Age 55? l Yes l No
l In-service Withdrawal of available funds other than hardship (if available under your plan).
l Permanent/Total Disability (Does not apply to 457(b) plans)
as of _____________(date). Termination Date: _____________
Attach Doctor’s Statement or Social Security Administration Documentation.
Other Distributions:
l Spousal Beneficiary l Non-Spousal Beneficiary l Alternate Payee under Qualified Domestic Relations Order (QDRO)
*See Information pages

VL 19552 VER 1/2022 2.0 DISBRSMNTM


page 1 of 3
Northeast
[Enter GroupValley Health Corporation 403(b) Plan
Name Here]
Mutual Fund Distribution Request Form
Group ID# [000000000]
✘ Group ID # 65886001
VALIC Retirement Services Company (VRSCO)
4. WITHHOLDING INFORMATION AND INSTRUCTIONS
If you do not have enough tax withheld, you are still liable for any taxes owed and may be subject to tax penalties for under-withholding.
Federal Income Tax (FIT) Withholding
FIT Withholding will be applied based on the defaults described below unless the referenced IRS Form is submitted. Current IRS Forms are
available on the IRS website at www.irs.gov.
• Certain distributions you receive from an employer sponsored qualified retirement plan (for example a 403(b), 401(k) or governmental 457(b) plan) that
are eligible to be rolled over to an IRA or qualified plan (“Eligible Rollover Distributions”, or ERDs; see “Special Tax Notice” for more information) are
subject to 20% mandatory FIT default rate on the taxable portion of the distribution. You cannot request withholding at a rate less than 20% for an ERD.
To request a rate higher than 20% attach a completed IRS Form W4-R. If a W4-R is not submitted with this request, 20% FIT will be withheld.
• Distributions from unfunded deferred compensation plans (including 457(b) plans of private tax exempt employers), where consistent with your
employer’s plans, are subject to wage bracket withholding. Attach a completed IRS Form W-4. If a W-4 is not provided with this request, wage bracket
withholding based on Single and 0 Exemptions will be applied. Wage bracket withholding does not apply to beneficiary accounts.
• 30% FIT (may be less depending on country of domicile and any applicable ratified income tax treaty) will be withheld on payments to an address
outside the United States. If you qualify for reduced withholding, submit an IRS Form W-8BEN.
• All other distributions generally are subject to a 10% FIT default rate on the taxable portion. To request a different rate or to request no federal tax
withholding attach a completed IRS Form W4-R. If a W4-R is not provided with this request, 10% FIT will be withheld.
State Income Tax (SIT) Withholding (if applicable)
States with SIT either require mandatory withholding or allow voluntary withholding. Withholding is based on your resident state on file. Each state determines
their specific state requirements, which may include a default rate, or require your election be provided on their state specific withholding form. If you do not
provide instructions OR your instructions are different than your resident’s state requirements, SIT will be withheld using the state’s requirements.
State Withholding Instructions
 DO NOT withhold any state taxes unless mandated by law.  DO withhold state taxes in the amount of ____________ %
(cannot be less than any mandatory withholding)
5. DELIVERY INSTRUCTIONS
If you have already provided information to receive an electronic funds transfer (EFT) your payment will be sent electronically. If you have not previously set this up,
your payment will be made by a check sent via USPS to the address of record on file.
To add or update your banking information so that your payment can be made via EFT, visit aig.com/RetirementServices and access your account. Please do not
include any bank information on this form.

6. SPOUSAL CONSENT
ERISA-covered and certain other employer plans require the client to state his/her marital status and the spouse to consent to this distribution. Not required
for 457 Deferred Compensation Plans. Please check the appropriate box below:
REQUIRED FOR CLIENT: Client Marital Status
l Not Married l Married
REQUIRED FOR SPOUSE: Spousal Consent
Under federal law, you have the right to receive a survivor benefit of at least 50% of the amount in this account if your spouse dies before you. As a result,
your spouse must have written consent before making withdrawals from his or her retirement account. If you consent to the withdrawal, you will not receive a
survivor benefit from the amount withdrawn. If you agree to the withdrawal, please read and sign the statement below and have your signature witnessed.
• I have read and understand the “Joint and Survivor Annuity and Qualified Annuity Benefit” section of the Information pages and I agree to the payment of
funds from my spouse’s retirement account.
• I understand and agree that I am giving up my right to receive a survivor benefit payment from VALIC Retirement Services Company for the amount being
paid and I release VALIC Retirement Services Company from all liability for making this payment.

_____________________________________________________ ____________________________________________________ ___________________


Spouse (Print Name) Spouse’s Signature Date
WITNESS BY NOTARY PUBLIC
STATE OF __________________________________________________ COUNTY OF _____________________________________________________
BEFORE ME, the undersigned, a Notary Public, personally appeared _____________________________________________________________________
who executed the above Spousal Consent as a free and voluntary act.
IN WITNESS THEREOF, I have signed my name and affixed my official notarial seal/stamp this ______ day of ____________, 20_____________________.
(SEAL/STAMP)
Notary Public:_____________________________________________________
My commission expires:_____________________________________________

VL 19552 VER 1/2022 2.0 DISBRSMNTM


page 2 of 3
Northeast
[Enter GroupValley Health Corporation 403(b) Plan
Name Here]
Mutual Fund Distribution Request Form
Group ID# [000000000]
VALIC Retirement Services Company (VRSCO)
Group ID # 65886001
7. CLIENT SIGNATURE
• I authorize the above distribution and certify that all statements, including marital statements, Signature Guarantee (if applicable)

are complete and accurate to the best of my knowledge


and belief.
• I have read and understand the information provided in the Special Tax Notice in the
Information pages of this form.
• I have read and understand the “Joint and Survivor Annuity and Qualified Annuity Benefit”
section of the Information pages. By signing below I am agreeing to waive any benefit or
right described in that section that would have been provided with respect to the amount that I
am withdrawing. I also understand that I have the right to revoke any waiver if a distribution has not already been made.

__________________________________________________________________________________ 05/01/2023
________________________
Client Signature Date

8. PLAN ADMINISTRATOR’S APPROVAL — IF APPLICABLE


• I approve this distribution in accordance with the current plan provisions and all applicable laws and regulations. I verify that the information provided on
this form for purposes of this distribution is correct to the best of my knowledge.
• Unless specified otherwise in the plan document, the Plan Administrator authorizes a participant who has terminated employment to leave his or her
vested portion of the account(s) listed on this form under the Plan as a deferred benefit, and to receive a distribution or make a qualified rollover from
these account(s) at any time in the future.

Spousal Consent – Please check the appropriate box below.


l I affirm that the client’s Spouse’s signature under the SPOUSAL CONSENT section of the form has been witnessed either by me or by a Notary Public.
l I affirm that the client has established to my satisfaction that spousal consent is not required under the SPOUSAL CONSENT section of the form.
l The Plan administrator’s signature does NOT serve as witness of the client’s Spouse’s signature under the SPOUSAL CONSENT section of the form.

__________________________________________________________________________________
Plan Administrator or Authorized Representative (Print Name)

__________________________________________________________________________________ ________________________
Plan Administrator or Authorized Representative Signature Date

Please fax this form to 1-877-202-0187


1-877-202-018 7 or mail to the address below for processing:

VALIC Document Control If overnight delivery: VALIC
VALIC Retirement Services
Retirement Services Company
Company
P.O. Box 15648 1050
1050 N. N. Western St.
Western St.
Amarillo, TX 79105-5648 Amarillo,TXTX79106-7011
Amarillo, 79106-7011

Questions about this form may be directed to 1-800-448-2542


1-800-448-254 2, Monday through Friday, 7 a.m. – 8 p.m. Central Time.

AIG Retirement Services represents AIG member companies - The Variable Annuity Life Insurance Company (VALIC) and its subsidiaries, VALIC Financial Advisors, Inc. (VFA) and
VALIC Retirement Services Company (VRSCO). All are members of American International Group, Inc. (AIG).
VL 19552 VER 1/2022 2.0 DISBRSMNTM
page 3 of 3
Information

VALIC Retirement Services Company (VRSCO)


QUALIFIED JOINT AND SURVIVOR ANNUITY AND QUALIFIED Lump-Sum Distribution
ANNUITY BENEFIT: FOR ERISA PLANS ONLY If you elect a lump-sum distribution, your benefit will be paid to you in
This notice should be provided to you at least 30 days, but no more than one payment. The amount of your benefit is the vested portion of your
180 days, before your proposed distribution date. account balance as of the valuation date used to calculate
your distribution.
If you are married, your retirement plan distributions will be paid to you
in the form of a Qualified Joint and Survivor Annuity (“QJSA”) unless Installments
you elect a different form of distribution. Under your QJSA, if your If you elect to receive your benefits in installments, you may specify the
spouse survives you, the plan will pay him or her at least 50% of the dollar amount and frequency of your payments. The period of time over
amount the plan had been paying to you, on the same frequency as which you receive these installments cannot be greater than your life
the payments to you. If you are not married, your benefit will be paid expectancy or the joint life and last survivor expectancy of you and your
monthly over your life and will end upon your death unless you elect a designated beneficiary. There are other IRS rules that may further limit
different form of distribution. This benefit is referred to as a Qualified the period over which you receive payments.
Annuity Benefit (“QAB”).
In order to elect one of these alternative forms of benefits you must
The plan may satisfy the QJSA or QAB by using your vested account waive your right to the QJSA or QAB, and if you are married, your
balance to purchase an annuity contract from an insurance company. spouse must also consent in writing. In addition, this written consent
The actual monthly payments made under the annuity contract will must be witnessed by a Notary Public or by your Plan Administrator.
depend on the value of your account balance, annuity purchase rates You are entitled to 30 days (but no more than 180 days) within which
used by the insurance company, your age, and if you are married, your to make this decision. Although you have at least 30 days to make this
spouse’s age at the time the distribution begins. decision, under some circumstances, you may waive this minimum
The following table reflects the relative values of monthly payments 30-day period, and if you submit a waiver of the QJSA or QAB less
from a Joint and Survivor Annuity and a Life Annuity, assuming a vested than 30 days after it is signed we will assume that you are waiving this
account balance of $5,000 and an interest rate of 6%. This table is notice period. Unless a waiver of the QJSA or QAB is made irrevocably,
based on the Annuity 2000 Mortality tables. The table is hypothetical you have the right to revoke the waiver and execute another waiver at a
and does not reflect the value of your individual benefit or the later time, up to the time when the benefit payments have started. You
actual payments you or your beneficiaries would receive. Please also have the right to defer receiving a distribution, subject to the terms
note that as the ages change, the payment amount will change. If of your employer’s plan as well as legal requirements that generally
none of the examples closely approximates your situation, you may require distributions to commence upon the later of attainment of age
obtain a more accurate value specific to your situation from your plan 73 (age 72 if you were born after June 30, 1949 and before January 1,
administrator or from your financial professional. 1951 & age 70 ½ if you were born before July 1, 1949), or retirement.
The investment options available to you, the right to change investment
Age at Benefit Starting Date options, and the fees imposed under the investment options will not be
Annuitant 70 65 60 55 50 45 40 35 affected by your decision to defer distributions.
Spouse 65 70 55 60 45 50 35 40

Monthly Payment
Annuitant Life
Only 39.62 35.35 32.38 30.27 28.75 27.61 26.76 26.13
Joint and
50% Survivor 35.47 33.65 30.21 29.26 27.53 26.99 26.07 25.76
Joint and
75% Survivor 33.71 32.86 29.23 28.78 26.95 26.70 25.73 25.58

This QJSA or QAB requirement may not apply to smaller account


balances (generally below $5,000) and will not apply if you have elected
another form of benefit. A partial withdrawal would be considered
another form of benefit for this purpose. Other alternate forms of benefits
that may be available under your employer’s plan and under your plan
investments may include:
Annuity
An annuity can provide you with payments for your life or for your life
and that of your beneficiary; payments for a specified period; payments
for your lifetime with a minimum guaranteed period; or a continuation
of payments to your surviving spouse that is different from the plan’s
percentage of the payments made to you. Generally, the more that the
form of payment guarantees, such as a minimum period of payments, or
payments to your surviving spouse or to another beneficiary, the more
that specified benefit amount will cost. There are IRS rules that may limit
the period during which payments may be made.

VL 19647-QJSA VER 2/2023 1.0 page 1 of 1


The Variable Annuity Life Insurance Company (VALIC) Information
VALIC Retirement Services Company (VRSCO)
SPECIAL TAX NOTICE private letter ruling granting a waiver. Payment is required to apply for a
The information in this notice applies to employer plans (a tax‑qualified private letter ruling with the IRS. The user fee for a private letter ruling
plan, section 403(b) plan, or governmental section 457(b) plan) (each is nonrefundable. For more information, see IRS Publication 590‑A,
referred to herein as “Plan”). You are receiving this notice because all or a Contributions to Individual Retirement Arrangements (IRAs).
portion of a payment you are receiving may be eligible to be rolled over to How much may I rollover? (for both designated Roth accounts and
an IRA or an employer plan, or if your payment is from a designated Roth accounts not designated as Roth accounts)
account (a type of account with special tax rules in some employer plans), If you wish to direct a rollover, you may direct a rollover of all or part of
to a Roth IRA or designated Roth account in an employer plan. This the amount eligible for rollover. Any payment from an employer plan or
notice is intended to help you decide whether to direct such a rollover. IRA is eligible for rollover, except:
You have the right to at least 30 days to consider your alternatives after • Certain payments spread over a period of at least 10 years or over your
receiving this notice. You may waive this review period. Your signature life or life expectancy (or the lives or joint life expectancy of you and
on this form will indicate that either you have had this 30‑day review or your beneficiary).
that you have chosen to waive it and you are requesting an immediate • Required minimum distributions after age 73 (age 72 if born after June
distribution. This notice does not describe any State or local income tax 30, 1949 and before January 1, 1951; age 70½ if born before July 1,
rules (including withholding rules). 1949) or after death.
GENERAL INFORMATION ABOUT ROLLOVERS • Hardship distributions (unforeseeable emergency distribution for
For accounts that are not designated Roth accounts. See below governmental section 457(b) plans).
“Payments From Designated Roth Accounts” for rollover rules regarding • Corrective distributions of contributions that exceed tax law limitations.
payments from designated Roth accounts in 401(k), 403(b) or
• Loans treated as deemed distributions (for example, loans in default due
governmental section 457(b) plans.
to missed payments before your employment ends). However, qualified
How can a rollover affect my taxes? plan loan offset amounts and plan loan offset amounts can be eligible
You will be taxed on a payment from the Plan if you do not direct a rollover distributions. See “Loans” and “Extended Rollover Deadline for
rollover. If you are under age 59½ and do not direct a rollover, you will Certain Offset Loans” below.
also have to pay a 10% additional income tax on early distributions • Payments of certain automatic enrollment contributions requested to be
(unless an exception applies). However, if you do a rollover, you will not withdrawn within 90 days of the first contribution.
have to pay tax until you receive payments later and the 10% additional
• Cost of life insurance paid by the Plan.
income tax will not apply if those payments are made after you are age
59½ (or if an exception applies). The Plan administrator or the payor can tell you what portion of a
payment is eligible for rollover.
What types of retirement accounts and plans may accept
my rollover? SPECIAL RULES AND OPTIONS
You may roll over the payment to either an IRA (an individual retirement If your payment includes after‑tax contributions.
account or individual retirement annuity) or another employer plan, (a tax After‑tax contributions included in a payment are not taxed. If a payment
qualified plan, section 403(b) plan, or governmental section 457(b) plan) is only part of your benefit, an allocable portion of your after‑tax
that will accept the rollover. Check with the administrator of that plan contributions is included in the payment, so you cannot take a payment
about whether the plan accepts rollovers and, if so, the types of rollovers of only after‑tax contributions. However, if you have pre‑1987 after‑tax
it accepts. The rules of the IRA or employer plan that holds the rollover contributions maintained in a separate account, a special rule may
will determine your investment options, fees, and rights to payment from apply to determine whether the after‑tax contributions are included in
the IRA or employer plan (for example, no spousal consent rules apply to a payment. In addition, special rules apply when you do a rollover, as
IRAs and IRAs may not provide loans). Further, the amount rolled over will described below.
become subject to the tax rules that apply to the IRA or employer plan. You may roll over to an IRA a payment that includes after‑tax contributions
How do I do a rollover? through either a direct rollover or a 60‑day rollover. You must keep track
There are two ways to do a rollover. You can do either a direct rollover or of the aggregate amount of the after‑tax contributions in all of your IRAs
a 60‑day rollover. (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
If you do a direct rollover, the Plan or IRA will make the payment directly
from the Plan and at the time the rest is paid to you, the portion directly
to your IRA or an employer plan. You should contact the IRA sponsor
rolled over consists first of the amount that would be taxable if not rolled
or the administrator of the employer plan for information on how to do a
over. For example, assume you are receiving a distribution of $12,000, of
direct rollover.
which $2,000 is after‑tax contributions. In this case, if you directly roll over
If you do not do a direct rollover, you may still do a rollover by making a $10,000 to an IRA that is not a Roth IRA, no amount is taxable because
deposit into an IRA or eligible employer plan that will accept it. You will the $2,000 amount not directly rolled over is treated as being after‑tax
have 60 days after you receive the payment to make the deposit. If you contributions. If you do a direct rollover of the entire amount paid from the
do not do a direct rollover, the Plan is required to withhold 20% of the Plan to two or more destinations at the same time, you may be able to
payment for federal income taxes. This means that, in order to roll over choose which destination receives the after‑tax contributions.
the entire payment in a 60‑day rollover, you must use other funds to make
Similarly, if you do a 60‑day rollover to an IRA of only a portion of the
up for the 20% withheld. If you do not roll over the entire amount of the
payment made to you, the after‑tax contributions are treated as rolled
payment, the portion not rolled over will be taxed and will be subject to
over last. For example, assume you are receiving a complete distribution
the 10% additional income tax for early distributions if you are under age
of your benefit which totals $12,000, of which $2,000 is after‑tax
59½ (unless an exception applies).
contributions. In this case, if you roll over $10,000 to an IRA that is not a
If you miss the 60-day rollover deadline (for both designated Roth Roth IRA in a 60‑day rollover, no amount is taxable because the $2,000
accounts and accounts not designated as Roth accounts). amount not rolled over is treated as being after‑tax contributions.
Generally, the 60‑day rollover deadline cannot be extended. However, You may roll over to an employer plan all of a payment that includes
the IRS has the limited authority to waive the deadline under certain after‑tax contributions, but only through a direct rollover (and only if the
extraordinary circumstances, such as when external events prevented receiving plan separately accounts for after‑tax contributions and is not
you from completing the rollover by the 60‑day rollover deadline. There a governmental section 457(b) plan). You can do a 60‑day rollover to an
are three ways to obtain a waiver of the 60‑day rollover requirement: employer plan of part of a payment that includes after‑tax contributions,
you qualify for an automatic waiver; you self‑certify that you met the but only up to the amount of the payment that would be taxable if not
requirements of a waiver and the IRS determines during an audit or rolled over.
your income tax return that you qualify for a waiver, or your receive a
VL 19647 VER 2/2023 1.0
The Variable Annuity Life Insurance Company (VALIC) Information
VALIC Retirement Services Company (VRSCO)
PAYMENTS FROM DESIGNATED ROTH ACCOUNTS not exceed the amount of the earnings in the payment. You cannot do a
How can a rollover affect my taxes? 60‑day rollover to an employer plan of any part of a qualified distribution.
After‑tax contributions included in a payment from a designated Roth If you receive a distribution that is a nonqualified distribution and you do
account are not taxed, but earnings might be taxed. The tax treatment not roll over an amount at least equal to the earnings allocable to the
of earnings included in the payment depends on whether the payment is distribution, you will be taxed on the amount of those earnings not rolled
a qualified distribution. If a payment is only part of your designated Roth over, including the 10% additional income tax on early distributions if you
account, the payment will include an allocable portion of the earnings in are under age 59½ (unless an exception applies).
your designated Roth account. If you do a direct rollover of only a portion of the amount paid from the
If the payment from the Plan is not a qualified distribution and you do not Plan and the portion is paid to you at the same time, the portion directly
do a rollover to a Roth IRA or a designated Roth account in an employer rolled over consists first of earnings.
plan, you will be taxed on the earnings in the payment. If you are under If you do not do a direct rollover and the payment is not a qualified
age 59½, a 10% additional income tax on early distributions (generally, distribution, the Plan is required to withhold 20% of the earnings for
distributions made before age 59½) will also apply to the earnings (unless federal income taxes (up to the amount of cash and property received
an exception applies). However, if you do a rollover, you will not have to other than employer stock). This means that, in order to roll over the
pay taxes currently on the earnings and you will not have to pay taxes later entire payment in a 60‑day rollover to a Roth IRA, you must use other
on payments that are qualified distributions. funds to make up for the 20% withheld.
If the payment from the Plan is a qualified distribution, you will not be ROLLOVERS OF BENEFICIARY/ALTERNATE PAYEE ACCOUNTS
taxed on any part of the payment even if you do not do a rollover. If you (for both designated Roth accounts and accounts not designated as
do a rollover, you will not be taxed on the amount you roll over and any Roth accounts)
earnings on the amount you roll over will not be taxed if paid later in a Payments after death of the participant. If you receive a distribution
qualified distribution. after the participant’s death that you do not roll over, the distribution
A qualified distribution from a designated Roth account in the Plan is a will generally be taxed in the same manner described elsewhere in this
payment made after you are age 59½ (or after your death or disability) notice. However, the 10% additional income tax for early distributions and
and after you have had a designated Roth account in the Plan for at least the special rules for public safety officers do not apply, and the special
5 years. In applying the 5‑year rule, you count from January 1st of the rule described under the section, “Special Tax Treatment for Certain
year your first contribution was made to the designated Roth account. Lump‑Sum Distributions,” applies only if the participant was born on or
However, if you did a direct rollover to a designated Roth account in the before January 1, 1936. Note that whether a payment from a designated
Plan from a designated Roth account in another employer plan, your Roth account (see above) is a qualified distribution generally depends
participation will count from January 1st of the year your first contribution on when the participant first made a contribution to the designated Roth
was made to the designated Roth account in the Plan or, if earlier, to the account in the Plan.
designated Roth account in the other employer plan. If you are a surviving spouse. If you receive a payment from the
What type of retirement accounts and plans may accept my rollover? Plan as the surviving spouse of a deceased participant, you have the
You may roll over the payment to either a Roth IRA (a Roth individual same rollover options that the participant would have had, as described
retirement account or Roth individual retirement annuity) or a designated elsewhere in this notice. In addition, if you choose to do a rollover to a
Roth account in an employer plan (a tax-qualified plan, section 403(b) traditional or Roth IRA, if applicable, you may treat the IRA as an inherited
plan, or governmental section 457 plan) that will accept the rollover. IRA or as your own. If you treat the IRA (either traditional or Roth) as
The rules of the Roth IRA or employer plan that holds the rollover will an inherited IRA, payments from the IRA will not be subject to the 10%
determine your investment options, fees, and rights to payment from the additional income tax for early distributions. However, if the participant
Roth IRA or employer plan (for example, ROTH IRAs are not subject to had started taking required minimum distributions, you will have to receive
spousal consent rules and Roth IRAs may not provide loans). Further, required minimum distributions from the inherited IRA. If the participant
the amount rolled over will become subject to the tax rules that apply to had not started taking required minimum distributions from the Plan, you
the Roth IRA or the designated Roth account in the employer Plan. In will not have to start receiving required minimum distributions from the
general, these tax rules are similar to those described elsewhere in this inherited IRA until the year the participant would have been age 73 (age
document, but differences include: 72 if born after June 30, 1949 and before January 1, 1951; age 70½ if
• If you do a rollover to a Roth IRA, all of your Roth IRAs will be born before July 1, 1949).
considered for purposes of determining whether you have satisfied the An IRA you treat as your own is treated like any other traditional IRA of
5‑year rule (counting from January 1st of the year for which your first yours, so that payments made to you before you are age 59½ will be
contribution was made to any of your Roth IRAs). subject to the 10% additional income tax for early distributions (unless an
• If you do a rollover to a Roth IRA, you will not be required to take a exception applies) and required minimum distributions from such IRA do
distribution from the Roth IRA during your lifetime and you must keep not have to start until after you are age 73 (age 72 if born after June 30,
track of the aggregate amount of the after‑tax contributions in all of your 1949 and before January 1, 1951; age 70½ if born before July 1, 1949).
Roth IRAs (in order to determine your taxable income for later Roth IRA An inherited Roth IRA you treat as your own is treated like any other Roth
payments that are not qualified distributions). IRA of yours, so that you will not have to receive any required minimum
distributions during your lifetime and earnings paid to you in a nonqualified
• Eligible rollover distributions from a Roth IRA can only be rolled over to distribution before you are age 59½ will be subject to the 10% additional
another Roth IRA. income tax for early distributions (unless an exception applies).
How do I do a rollover? If you are a surviving beneficiary other than a spouse. If you receive
There are two ways to do a rollover. You can either do a direct rollover or a payment from the Plan because of the participant’s death and you are
a 60‑day rollover. a designated beneficiary other than a surviving spouse, the only rollover
If you do a direct rollover, the Plan will make the payment directly to your option you have is to do a direct rollover to an inherited traditional or
Roth IRA or designated Roth account in an employer plan. You should Roth IRA, as applicable. Payments from the inherited IRA (even if a
contact the Roth IRA sponsor or the administrator of the employer plan nonqualified distribution from a Roth IRA) will not be subject to the 10%
for information on how to do a direct rollover. additional income tax for early distributions. You will have to receive
If you do not do a direct rollover, you may still do a rollover by making a required minimum distributions from the inherited traditional or Roth IRA.
deposit within 60 days into a Roth IRA, whether the payment is a qualified Payments under a qualified domestic relations order. If you are the
or nonqualified distribution. In addition, you can do a rollover by making spouse or former spouse of the participant who receives a payment from
a deposit within 60 days into a designated Roth account in an employer the Plan under a qualified domestic relations order (QDRO), you generally
plan if the payment is a nonqualified distribution and the rollover does have the same options the participant would have (for example, you may

VL 19647 VER 2/2023 1.0


The Variable Annuity Life Insurance Company (VALIC) Information
VALIC Retirement Services Company (VRSCO)
roll over the payment to your own IRA or an eligible employer plan that are distributed by tax return deadline for the year (including extensions)
will accept it). Payments under the QDRO will not be subject to the 10% and no deduction is allowed for the excess contribution.
additional income tax for early distributions. Note: Eligible rollovers into a governmental section 457(b) plan that were
If I don’t do a rollover, will I have to pay the 10% additional income previously subject to the 10% additional income tax for early distributions
tax on early distributions? will continue to be subject to that penalty at the time of withdrawal unless
If you are under age 59½, you will have to pay the 10% additional income you are over age 59½ or some other exception applies.
tax on early distributions for any taxable payment from an employer IN‑PLAN ROLLOVER TO A DESIGNATED ROTH ACCOUNT
plan (including amounts withheld for income tax) that you do not roll You cannot roll over a taxable distribution to a designated Roth account
over, unless one of the exceptions listed below applies. In the case of in another employer’s plan. However, you can convert the taxable
designated Roth accounts, these taxable payments include earnings distribution into a designated Roth account in the distributing Plan.
allocated to the payment that are not qualified distributions if you are • If you roll over the taxable account to a designated Roth account in the
under age 59½. This tax is in addition to the regular income tax on the same Plan, the amount rolled over (reduced by any after‑tax amounts
payment not rolled over. directly rolled over) will be taxed. However, the 10% additional income
The 10% additional income tax does not apply to the following payments tax for early distributions will not apply (unless you take the amount
from an employer plan or IRA: rolled over out of the designated Roth account within the 5‑year period
• Payments made after you separate from service if you will be at least that begins on January 1st of the year of the rollover).
age 55 in the year of the separation (does not apply to payments from • If you roll over taxable account to a designated Roth account in the
an IRA). same Plan, later payments from the designated Roth account that are
• Payments that start after you separate from service if paid at least qualified distributions will not be taxed (including earnings after the
annually in equal or close to equal amounts over your life or life rollover). A qualified distribution from a designated Roth account is a
expectancy (or the lives or joint life expectancy of you and your payment made both after you attain age 59½ (or after your death or
beneficiary) (exception applies to IRA without regard to separation disability) and after you have had a designated Roth account in the
from service). Plan for a period of at least 5 years. The 5‑year period described in
• Payments from a governmental plan made after you separate from the preceding sentence begins on January 1st of the year your first
service if you are a qualified public safety employee and you (1) will be contribution was made to the designated Roth account. However, if you
at least age 50 in the year of the separation or (2) have at least 25 years made a direct rollover to a designated Roth account in the Plan from
of service under the Plan. a designated Roth account in a plan of another employer, the 5‑year
• Payments from a tax-qualified plan or section 403(b) plan made after period begins on January 1st of the year your first contribution was
you separate from service if you provided firefighting services and you made to the designated Roth account in the Plan or, if earlier, to the
(1) will be at least age 50 in the year of the separation or (2) have at designated Roth account in the plan of the other employer. Payments
least 25 years of service under the Plan. from the designated Roth account that are not qualified distributions
will be taxed to the extent allocable to earnings after the rollover,
• Payments made due to disability. including the 10% additional income tax on early distributions (unless
• Payments made while you are terminally ill. an exception applies). With respect to taxable years beginning after
• Payments after your death. 2023, you do not have to take required minimum distributions from a
• Payments from a governmental section 457(b) plan, unless the payment designated Roth account during your lifetime.
is from a separate account holding rollover contributions that were made • If the Plan permits an in‑plan Roth direct rollover option for amounts that
to the Plan from a qualified plan, a section 403(b) plan, or an IRA. are not otherwise distributable under the terms of the Plan, the Plan is
• Corrective distributions of contributions that exceed tax law limitations. not required to permit any other rollover or distribution options of such
amounts. For more information, please contact your Plan administrator.
• Payments made directly to the government to satisfy a federal tax levy.
ROLLOVERS TO A ROTH IRA
• Cost of life insurance paid by the Plan.
If you roll over the payment from the Plan to a Roth IRA, a special rule
• Payments made under a qualified domestic relations order (QDRO) (not
applies under which the amount of the payment rolled over (reduced
applicable to IRA; special rule applies for IRAs under which, as part of
by any after‑tax amounts) will be taxed. However, the 10% additional
a divorce or separation agreement, a tax‑free transfer may be made income tax on early distributions will not apply (unless you take the
directly to an IRA of a spouse or former spouse). amount rolled over out of the Roth IRA within 5 years, counting from
• Payments up to the amount of your deductible medical expenses January 1st of the year of the rollover).
(without regard to whether you itemize deductions for the taxable year). If you roll over the payment to a Roth IRA, later payments from the Roth
• Certain payments made while you are on active duty if you were a IRA that are qualified distributions will not be taxed (including earnings
member of a reserve component called to duty after September 11, after the rollover). A qualified distribution from a Roth IRA is a payment
2001 for more than 179 days. made after you are age 59½ (or after your death or disability, or as a
• Payments of certain automatic enrollment contributions requested to be qualified first‑time homebuyer distribution of up to $10,000) and after you
withdrawn within 90 days of the first contribution. have had a Roth IRA for at least 5 years. In applying this 5‑year rule,
• Phased retirement payments made to federal employees. you count from January 1st of the year for which your first contribution
• Roth conversions/rollovers. was made to a Roth IRA. Payments from the Roth IRA that are not
qualified distributions will be taxed to the extent of earnings after the
• Payments of up to $5,000 made to you from a defined contribution plan rollover, including the 10% additional income tax for early distributions
if the payment is a qualified birth or adoption distribution. (unless an exception applies). You do not have to take required minimum
• Payments of up to $22,000 made in connection with distributions from a Roth IRA during your lifetime. For more information,
federally-declared disasters. see IRS Publication 590‑A, Contributions to Individual Retirement
• IRA Only: (1) payments for qualified higher education expenses, (2) Arrangements (IRAs), and IRS Publication 590‑B, Distributions from
payments up to $10,000 used in a qualified first‑time home purchase, Individual Retirement Arrangements (IRAs).
(3) payments for health insurance premiums after you have received LOANS
unemployment compensation for 12 consecutive weeks (or would If you request a total surrender/withdrawal of your Plan account and
have been eligible to receive unemployment compensation but for you have an outstanding loan, the account balance will be reduced by
self‑employed status), and (4) payments of net income attributable to an the outstanding loan balance and if applicable outstanding loan security
excess IRA contribution made in a calendar year where such amounts will be returned to the account. The loan offset amount is treated as a

VL 19647 VER 2/2023 1.0


The Variable Annuity Life Insurance Company (VALIC) Information
VALIC Retirement Services Company (VRSCO)
distribution to you at the time of the offset and will be taxed (including is generally required to withhold 30% of the payment for federal income
the 10% additional income tax on early distributions, unless an exception taxes. If the amount withheld exceeds the amount of tax you owe (as
applies) (in the case of a nonqualified distribution from a designated Roth may happen if you do a 60‑day rollover), you may request an income
account, only to the extent of the earnings in the loan offset) unless you tax refund by filing Form 1040NR and attaching your Form 1042‑S. See
do a 60‑day rollover (or are entitled to an extended rollover—see next Form W‑8BEN for claiming that you are entitled to a reduced rate of
section) in the amount of the loan offset to an IRA or employer plan (or withholding under an income tax treaty. For more information, see also
in the amount of the nonqualified distribution earnings to a Roth IRA or IRS Publication 519, U.S. Tax Guide for Aliens, and IRS Publication 515,
designated Roth account in any employer plan). You may also choose to Withholding of Tax on Nonresident Aliens and Foreign Entities.
pay off the outstanding loan balance prior to the surrender by submitting OTHER SPECIAL RULES
payment in full. • If a payment is one in a series of payments for less than 10 years, your
EXTENDED ROLLOVER DEADLINE FOR CERTAIN OFFSET LOANS choice whether to make a direct rollover will apply to all later payments
A participant who incurs a “qualified” plan loan offset will have until in the series (unless you make a different choice for later payments).
the participant’s tax return due date (including extensions) for the year • For a traditional IRA, if your payments for the year are less than $200
in which the offset occurred to make a rollover of up to 100% of the (not including payments from a designated Roth account in the Plan),
amount of the qualified plan loan offset. A “qualified” plan loan offset the Plan is not required to allow you to do a direct rollover and is not
is a plan loan offset that occurs as the direct result of termination of required to withhold for federal income taxes. However, you may do a
employment or the employer’s termination of the plan. 60‑day rollover.
EXTENDED ROLLOVER DEADLINE FOR CERTAIN QUALIFIED • For a designated Roth account, if your payments for the year (only
BIRTH OR ADOPTION DISTRIBUTIONS including payments from the designated Roth account in the Plan)
Beginning after December 31, 2019, a participant who incurs a qualified are less than $200, the Plan is not required to allow you to do a direct
birth or adoption distribution may rollover of up to 100% of the amount of rollover and is not required to withhold federal income taxes. However,
the qualified birth or adoption distribution to the plan or an IRA without you can do a 60-day rollover.
regard to the normal 60‑day rollover time limit . • Unless you elect otherwise, a mandatory cashout of more than $1,000
PAYMENT FROM A GOVERNMENTAL SECTION 457(B) PLAN will be directly rolled over to an IRA chosen by the Plan administrator.
If the Plan is a governmental section 457(b) plan, the same rules A mandatory cashout is a payment from a plan to a participant made
described elsewhere in this notice generally apply, allowing you to roll before age 62 (or normal retirement age, if later) and without consent,
over the payment to an IRA or an employer plan that accepts rollovers. where the participant’s benefit does not exceed $5,000 (not including
One difference is that, if you do not do a rollover, you will not have to any amounts held under the plan as a result of a prior rollover made to
pay the 10% additional income tax on early distributions from the Plan the plan).
even if you are under age 59½ (unless the payment is from a separate • You may have special rollover rights if you recently served in the
account holding rollover contributions that were made to the Plan from a U.S. Armed Forces. For more information, see IRS Publication 3,
tax-qualified plan, a section 403(b) plan, or an IRA). Armed Forces’ Tax Guide.
However, if you do a rollover to an IRA or to an employer plan that is • You may have special rollover rights if you were affected by a
not a governmental section 457(b) plan, a later distribution made before federally declared disaster. For more information on special rollover
age 59½ will be subject to the 10% additional income tax on early rights related to disaster relief, see the IRS website at www.irs.gov
distributions (unless an exception applies). Other differences include FOR MORE INFORMATION
that you cannot do a rollover if the payment is due to an “unforeseeable You may wish to consult with the Plan administrator or a professional tax
emergency” and the special rules under “If you were born on or before adviser, before taking a payment from the Plan or IRA. Also, you can find
January 1, 1936” do not apply. more detailed information on the federal tax treatment of payments from
EXTENDED ROLLOVER DEADLINE FOR CERTAIN employer plans and IRAs in: IRS Publication 575, Pension and Annuity
CORONAVIRUS‑RELATED DISTRIBUTIONS Income; IRS Publication 590‑A, Contributions to Individual Retirement
For coronavirus‑related distributions made on or after March 27, 2020, Arrangements (IRAs); IRS Publication 590‑B, Distributions from Individual
and before December 31 2020, up to 100% of such distributions may Retirement Arrangements (IRAs); and IRS Publication 571, Tax‑Sheltered
be rolled over to the plan or an IRA without regard to the normal 60‑day Annuity Plans (403(b) Plans). These publications are available from a local
rollover time limit for up to three years from the date of the distribution. IRS office, on the web at www.irs.gov or by calling 1‑800‑TAX‑FORM.
IF YOU RECEIVE A NONQUALIFIED DISTRIBUTION AND YOU WERE ADDITIONAL INFORMATION
BORN BEFORE JANUARY 1, 1936 DISTRIBUTABLE EVENT
If you were born on or before January 1, 1936 and receive a lump‑sum Generally a distributable event includes attainment of age 59½ (Before
distribution (including a nonqualified distribution from a designated January 1, 2020 attainment of age 70½ for governmental section 457(b)
Roth account) that you do not roll over, special rules for calculating plans), severance from employment, disability or death. However, the
the amount of the tax on the payment (or the earnings in the payment employer’s plan may place additional restrictions that must also be
for a nonqualified distribution) might apply to you (not applicable to met prior to a distribution. If you have met a distributable event, you
governmental section 457(b) plan distributions). For more information, may request a rollover of funds to any eligible plan type or a transfer
see IRS Publication 575, Pension and Annuity Income. to a like plan type. If you wish to move funds from your VALIC 403(b)
ELIGIBLE RETIRED PUBLIC SAFETY OFFICER account to another 403(b) account via a rollover distribution, and have
If the Plan is a governmental plan, you retired as a public safety officer, made contributions prior to January 1, 1987, those amounts may lose
and your retirement was by reason of disability or was after normal a grandfathered status that can impact future required distributions.
retirement age, you can exclude from your taxable income Plan payments However, movement of funds from your VALIC 403(b) account to another
(including nonqualified distributions from designated Roth accounts) paid 403(b) account via a transfer distribution may retain the status. For more
as premiums to an accident or health plan (or a qualified long‑term care information, please call 1‑800‑448‑2542.
insurance contract) that your employer maintains for you, your spouse, or TRANSFERS
your dependents, up to a maximum of $3,000 annually. For this purpose, Transfers to a like plan will not be taxed or reported to the IRS. Generally,
a public safety officer is a law enforcement officer, firefighter, chaplain, or transfers are allowed regardless of employment status. However, your
member of a rescue squad or ambulance crew. employer’s Plan may restrict you to authorized carriers. Transferred
NONRESIDENT ALIEN amounts generally become subject to the requirements of the plan
If you are a nonresident alien and you do not do a direct rollover to a receiving the transfer as though originally contributed to that plan.
U.S. IRA or U.S. employer plan, instead of withholding 20%, the Plan
VL 19647 VER 2/2023 1.0
The Variable Annuity Life Insurance Company (VALIC) Information
VALIC Retirement Services Company (VRSCO)
For distributions occurring after January 1, 2015, under federal tax rules
individuals cannot make more than one nontaxable 60‑day IRA rollover
within any one‑year period, even if the rollovers involve different IRAs.
The one‑rollover per year limitation does not apply to a rollover to or from
a qualified plan nor does it apply to IRA trustee‑to‑trustee transfers. IRA
owners requesting a distribution for a rollover should be advised that they
have the option to request a trustee‑to‑trustee transfer from one IRA to
another IRA.
LIVING BENEFIT OPTIONS
If you have chosen a living benefit option with your annuity contract,
withdrawals from the contract will reduce the account value and may
reduce or cancel benefits of the living‑benefit option. Withdrawals
exceeding the Maximum Annual Withdrawal Amount may reduce future
Maximum Annual Withdrawal Amounts and reduce or eliminate any
eligible income credit. Minimum distribution amounts calculated for each
year will include the value of the living benefit. One year’s required
minimum distribution based solely on the value of each individual
account will not be treated as an excess withdrawal, but may reduce
the Maximum Withdrawal Period and reduce or eliminate any eligible
income credit. See your contract endorsement.
PRIVATE TAX-EXEMPT EMPLOYER DEFERRED COMPENSATION PLANS
Section 457(b) deferred compensation plans sponsored by private
tax‑exempt employers require participants to make an irrevocable election
regarding the distribution of benefits. Commencement of payments cannot
be later than April 1st of the year following the year you attain age 73
(age 72 if born after June 30, 1949 and before January 1, 1951; age 70½
if born before July 1, 1949) unless you are still working for the plan’s
sponsor. Please contact your plan administrator for more information.
Distributions from a Section 457(b) plan sponsored by a private
tax‑exempt employer are not eligible for a rollover to another plan or IRA.
INTERNAL REVENUE SERVICE (IRS) AND DEPARTMENT OF
LABOR (DOL) GUIDANCE ON MARRIAGE
For federal tax law and ERISA purposes, under current IRS and DOL
guidance (1) a same‑sex marriage that was valid in the state or country
it was entered into will be recognized by the IRS or DOL, regardless
of the married couple’s place of domicile; and (2) although a state may
recognize domestic partnerships or civil unions, the terms “spouse,”
“husband and wife,” “husband,” and “wife” do not include individuals
who have entered into a registered domestic partnership, civil union, or
other similar formal relationship recognized under state law that is not
denominated as a marriage under the laws of that state.
Please send completed forms to:
VALIC
VALICDocument
Document Control
Control
P.O.Box
P.O. Box15648
15648
Amarillo,
Amarillo, TXTX 79105-5648
79105‑5648

VALIC Retirement Services Company


Overnight delivery:
1050 Document
VALIC N. Western St.
Control
Amarillo, TX 79106-7011
1050 N. Western St.
Amarillo, TX 79106‑7011

Call 1-800-448-2542 for assistance.

VL 19647 VER 2/2023 1.0

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