Read Microsoft Word - DC-4263-0212 Incoming Assets Form NMEX.docx text version


Nationwide Retirement Solutions (NRS) adheres to the USA Patriot Act's Anti-Money Laundering program requirements. NRS actively monitors and prohibits illegal money laundering of concealed funds generated from a criminal enterprise. Please carefully complete all required sections of this document. We are unable to process forms with incomplete or missing information. If you require assistance in completing this form or need additional information, please contact us at 1-866-827-NMEX. Nationwide Retirement Solutions P.O. Box 182797, PW-04-08 Columbus, Ohio 43218-2797

SECTION I: Account Holder Information

Name Last Number and Street State Employer Number First Middle Apt./Suite Zip Code Social Security Number Home Phone Number (Include Area Code) ( ) Work Phone Number (Include Area Code) ( ) E-mail Address

Current Address City Employer Name

SECTION II: Rollover/Transfer Funds From:

Plan Type: 401(a)/DROP plan 401(k) plan 403(b)/403(a) plan 457(b) plan Traditional IRA 457 Spousal Benefit Account Number Number and Street State Zip Code Contact Name Telephone Number Carrier/Custodian Name Address City

SECTION III: Rollover/Transfer Funds

Plan Type: 457 plan Make check payable to: Mail check to:


Amount to Rollover/Transfer: Partial dollar amount $______________________ Total account balance

Please liquidate and transfer all securities necessary to complete this transaction.

Nationwide Retirement Solutions FBO (Participant Name, SS#) Nationwide Retirement Solutions PO Box 71-3101 Columbus, Ohio 43218-3101

The difference between a transfer and rollover: Following a Transfer, withdrawal of assets is permitted only when the account holder meets a distributable event. (e.g. Severance of service or age 70 ½) Following a Rollover, withdrawal of assets is permitted at any time pursuant to the account holder's request Please make your selection: TRANSFER ROLLOVER

SECTION IV: Investment Direction to Nationwide Retirement Solutions

Credit my rollover/transfer according to the current allocation on file OR Credit my rollover/transfer as listed below: INVESTMENT OPTION(S) PERCENT % % % % % 100 %

If you do not indicate your allocation choices or if you select closed investment options, your rollover will be credited to your current allocations.


SECTION V: Authorization

I acknowledge that I have received and read the fund prospectuses for the investment options I have elected above. I understand that my direct rollover/transfer will become subject to the terms and conditions of the plan. I certify that I satisfy the requirements for making a tax-free rollover/transfer into an eligible retirement plan.* NRS is entitled to rely fully on my certification. I expressly assume responsibility for tax consequences relating to this rollover/transfer, and I agree that NRS shall not be responsible for those tax consequences. Upon receipt, I hereby request my funds to be invested as directed on this form. Nationwide Retirement Solutions hereby agrees to accept the rollover/transfer described herein and upon receipt will deposit the proceeds within 5 business days in the account established on behalf of the individual's eligible employer. * Please reference important disclosure on the back

Account Holder's Signature


Retirement Specialist




COPY ­ Account Holder

Disclosure for Rollover Assets Some 457(b) Plan participants who leave one governmental employer and accept a position with a new governmental employer, have the option to TRANSFER or ROLLOVER their assets from the first employer to the new employer's 457(b) plan. The choice of transfer or rollover will determine when the assets are available for distribution from the State of New Mexico Deferred Compensation Plan administered by Nationwide Retirement Solutions (NRS). The difference between a transfer and rollover: Following a 457(b) to 457(b) TRANSFER, withdrawal of assets is permitted only when the account holder meets a distributable event (i.e. severance from employment, or age 70 1/2). The 457(b) to 457(b) transfer assets will be deposited to the existing 457(b) account, and there will only be one $52.00 annual plan administration charge. Following a ROLLOVER, withdrawal of assets is permitted at any time pursuant to the account holder's request. The 401(a), 401(k), 403(b), IRS or other 457(b) roll-over in of assets will be deposited into a separate sub-account subject to an additional $52.00 annual plan administrative charge, which is in addition to the $52.00 plan administration charge on the existing 457(b) Deferred Compensation Account.

PLEASE NOTE: Some mutual funds may impose a short-term trade fee. Please read the underlying prospectuses carefully.



COPY ­ Account Holder


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