DRS D 114B 8/18 Page 1 of 5

Deferred Compensation Program (DCP)Beneficiary Distribution RequestUse this form to withdraw payments from the inherited account within the next 12 months.

Send completed form to:Department of Retirement SystemsDeferred Compensation ProgramPO Box 48380 ꔷ Olympia, WA 98504-8380

drs.wa.gov/dcp ꔷ Fax: 360.586.5474888.327.5596 ꔷ TTY: 711

*DRSD114B*

Please complete the other side of this form as well.

Payment Options (Organizations, estates and trusts must select 100% Lump Sum Cash Distribution)c 1. Postpone distribution, no disbursement

This option only transfers the funds to your name. You will not receive payments until you request a withdrawal.

c 2. Lump Sum Cash DistributionAmount requested: c 100% of balance c Partial payment of $

c 4. Annuity Purchase (Skip the Rollover Election sections and sign the back of this form.)

c 3. Installment Payments (please select one option from each section A and B)A. Payment frequency c Monthly c Quarterly c Semi-Annually c Annually

B. Payment amount or duration

c Payments of $ until account balance is exhaustedc Payments projected to exhaust the account balance in yearsc Equal payments until the account is exhausted during my life expectancyc Required Minimum Distribution (RMD)

Type of Plan, Payment and Liquidation MethodDistribute Contributions From (check applicable plan): Payment Method

c Use ADD on Filec New ADDc Check

Liquidation Methodc Savings pool first and then pro-rata across

other fundsc Pro-rata across all funds and sources

c DCP 457 Planc Individual Retirement Plan (IRA)

c 401(a) or (k)c 403(b)

Participant and Beneficiary InformationParticipant Name (Last, First, Middle) Date of Death (mm/dd/yyyy) Participant Social Security Number

Beneficiary Name (Last, First, Middle) Beneficiary Birthdate Beneficiary Social Security Number

Beneficiary Mailing Address City State ZIP

Distribution Date: Installment payments are processed any day of the month with exception of the last three calendar days.

(mm/dd/yyyy) Phone Number

Payee Type (check one)c Spouse c Non Spouse

Distribution

Before completing this section, please read the Special Tax Notice Regarding Plan Payments. Under the tax law, at least 30 days normally must pass between receipt of the Special Tax Notice and your payment. By completing and returning your Distribution Request form sooner, you are waiving your right to the 30-day period for receiving the special tax notice.c 1. Distribution to Me: I understand that 20% of my payment will be withheld for federal taxes. (If you choose this

option, do not fill out “Rollover Election: Receiving Financial Institution” section.)

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Signature Required

Form W-9 Substitute: Under penalties of perjury, I certify that: • The Social Security number shown on this form is my correct number.

• I am a U.S. Citizen or a U.S. resident alien. (If you are a non-resident alien, you may be subject to non-resident alien withholding tax rules.)

I understand that unless I am eligible and elect a rollover to a traditional IRA or eligible employer plan, my distribution may be subject to federal income tax.This request supersedes any previous distribution request and is subject to approval by the Department of Retirement Systems.

Signature Date

Your Social Security number is needed so DRS can report to the IRS any funds paid to you. DRS will not disclose your Social Security number unless required to do so by law. See IRC sections 6041(a) and 6109.

For DCP Use OnlyBalance as of by

Rollover Election: Plan Selection

Complete the Rollover Election sections on this page if you are requesting a direct rollover.c 2. Entire Distribution Directly Rolled Over: I elect to have my entire distribution directly rolled over to the

following plan. If you are selecting more than one plan, contact DCP. Non-spouse beneficiaries are only allowed to roll over to an IRA that has been properly established as an inherited IRA.Plan Type: c 401(a)

c Traditional IRAc SEP IRA

c 401(k)c Roth IRAc Inherited Roth IRA

c 403(b)c Inherited Traditional IRA

c Govt 457

c 3. Part Rolled Over and Remainder Distributed to Me: I elect to have a portion of my funds directly rolled over to the following plan and the remainder of my funds paid directly to me. I understand that 20% of the part not directly rolled over will be withheld for federal taxes. Non-spouse beneficiaries are only allowed to roll over to an IRA that has been properly established as an inherited IRA.Plan Type: c 401(a)

c Traditional IRAc SEP IRA

c 401(k)c Roth IRAc Inherited Roth IRA

c 403(b)c Inherited Traditional IRA

c Govt 457

Rollover Election: Receiving Financial InstitutionName of Plan Amount Rolled Over as $ or %

Make Check Payable To Account Number Phone Number

Financial Institution Mailing Address City State ZIP

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Participant and Beneficiary InformationUse your legal name and mailing address.

Distribution Date: Choose any day of the month with the exception of the last three calendar days. The earliest date payment can be issued is 30 days after notification of the participant’s death.

Type of Plan, Payment and Liquidation MethodIndicate which plan you are requesting distribution from, how you would like to receive the payment and choice of liquidation method.

• Distribute Contributions From: DCP 457 Plan funds include deferrals (both current and rolled in). IRA, 401(a) or (k) and 403(b) are funds you have rolled in from another investment plan. If you are requesting distribution from a plan other than a 457 plan, there may be additional taxes. See the Special Tax Notice Regarding Plan Payment. IRA payments are subject to 10% withholding for federal taxes unless IRS Form W-4P is completed.

• Payment Method: Authorization for Direct Deposit (ADD) on file, new ADD or check. Receipt of payment for EFT will be 2-3 business days from date of liquidation; checks will be received 5-7 business days from date of liquidation.

• Liquidation Method: Savings Pool first and then pro-rata across other funds (If your balance in the Savings Pool does not meet the payment amount then payment will be pro-rata.) or pro-rata across all funds and sources.

If no selection is made, payment will default to pro-rata across all funds.

Payment Options The minimum payment amount is $50 monthly/$600 annually.

1. Postpone DistributionCheck this box to delay payment to a later date.

2. Lump Sum DistributionPayments for full or partial lump sums take about seven days to process. For any lump sum distribution that is not a rollover, select Distribution to Me in the Distribution section to acknowledge that 20% of your lump sum will be withheld for federal taxes. Taxes are not withheld for rollovers.

100% of balance: All your funds will be distributed in one lump sum. To request a lump sum be issued as soon as possible, use the current month, day and year for the distribution date. To roll over a lump sum distribution, also complete the Rollover Election sections on the back of the form.

Partial payment: If you choose a partial payment paid directly to you, select Distribution to Me in the Distribution section. If you are rolling your partial payment, complete the Rollover Election sections on the back of the form.

3. Installment PaymentsInstallments are a series of payments in an amount and frequency you choose. These payments are processed any day of the month with the exception of the last three calendar days. Select a payment frequency (A) and a payment amount or duration (B).

A. Payment Frequency: Choose how often you wish to receive installments.

B. Payment amount or duration: Select your installment type to determine the amount or duration of your payments.

DCP Form Instructions

Beneficiary Distribution Request

Send completed form to:Department of Retirement SystemsDeferred Compensation ProgramPO Box 48380 ꔷ Olympia, WA 98504-8380

drs.wa.gov/dcp ꔷ 888.327.5596

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B. Payment amount or duration (continued)c Payments of $xx until account balance is exhausted: If your installments are expected to be paid over a period of less than 10 years, also complete the Rollover Election on the back of the form. If your installments are expected to be paid over a period of 10 or more years, you must complete IRS Form W-4P to choose withholding of income tax. If you do not return a completed IRS Form W-4P, taxes will be withheld on your payments as if you are married and claim three allowances.

c Payments projected to exhaust the account balance in xx years: Each installment payment will be calculated by dividing your remaining account balance by the remaining number of installments. This results in your payment amount changing each month. Example: 10 years of monthly payments equals 120 payments.

• If your installments will be paid over a period of less than 10 years, also select Distribution to Me in the Distribution section.

• If your installments are expected to be paid over a period of 10 years or more complete IRS Form W-4P to choose withholding of income tax. If you do not return a completed IRS Form W-4P, taxes will be withheld on your payments as if you are married and claim three allowances.

c Equal payments until the account is exhausted during my life expectancy: For a spouse beneficiary, your payment will be recalculated annually in January by multiplying your prior year’s Dec. 31 account balance by an expected yield, then dividing that total by the single life expectancy years based upon your birth date. Your distribution amount will adjust each year as your account balance, expected yield and life expectancy change.

For a non-spouse beneficiary, your first payment will be calculated using your life expectancy years determined by your birth date at the time you begin payment. Your payments will be recalculated in January each year by reducing the life expectancy (at the time payment begins) by one year. Complete IRS Form W-4P to choose withholding of income tax. If you do not return a completed IRS Form W-4P, taxes will be withheld on your payments as if you are married and claim three allowances.

c Required Minimum Distribution (RMD): Choose this option if the deceased spouse was age 70 ½ or older and you wish to receive the minimum amount required by law. In the year of the participant’s death, your account will be calculated by dividing the prior year’s Dec. 31 account balance by the deceased spouse’s distribution period determined using the Uniform Lifetime table. Every year thereafter the minimum distribution will be based on your age and the distribution period on the single life expectancy table. Complete IRS form W-4P to choose withholding of income tax. If you do not complete and return the W-4P, taxes will be withheld on your payments at 10%.

4. Annuity (spouse beneficiary only)An annuity is a contract between you and an insurance company establishing a fixed monthly payment amount for life. If you’re interested in an annuity purchase, contact 888-327-5596, to discuss options and receive a quote.

DCP Form Instructions continued

Beneficiary Distribution Request

Send completed form to:Department of Retirement SystemsDeferred Compensation ProgramPO Box 48380 ꔷ Olympia, WA 98504-8380

drs.wa.gov/dcp ꔷ 888.327.5596

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Rollover Election SectionsBefore completing the Rollover Election, read the Special Tax Notice Regarding Plan Payments (drs.wa.gov/dcp/assets/dcptaxnotice.pdf). Under the tax law, typically at least 30 days must pass between your receipt of the Special Tax Notice and your payment. By completing and returning this form sooner, you are waiving your right to this 30-day period.

Non-spouse beneficiaries are only allowed to roll over to an IRA that has been properly established as an Inherited IRA.

For a distribution, You have the following choices: c Entire Distribution Directly Rolled Over: The entire payment can be directly rolled over to an IRA or other eligible employer plan. Except for a Roth IRA, you will not owe taxes in the year your payment is directly rolled over. Instead your taxes will be deferred until you receive payment from the traditional IRA or other plan. A check, issued to the receiving financial institution or employer plan, will be mailed directly to the financial institution. Check box 2, Entire Distribution Directly Rolled Over and select Plan Type. Also complete the Receiving Financial Institution section.

c Part Rolled Over and Remainder Distributed to Me: For this choice, you need to have at least $200 directly rolled over. A part of your payment can be directly rolled over and the remaining part can be distributed to you. 20% of the part that is not rolled over will be automatically withheld for federal taxes. The remaining 80% will be paid to you. A check for the rollover portions will be issued to the receiving financial institution or employer plan, and mailed directly to the financial institution. Check box 3, Part Rolled Over and Remainder Distributed to Me and select Plan Type. Also complete the Receiving Financial Institution information on the back of the form.

Be sure to include the following in your submission:

• Completed Beneficiary Distribution Request form

• Copy of participant’s death certificate

• Form W-4P (if required)

• Direct Deposit form (if required)

DCP Form Instructions continued

Beneficiary Distribution Request

Send completed form to:Department of Retirement SystemsDeferred Compensation ProgramPO Box 48380 ꔷ Olympia, WA 98504-8380

drs.wa.gov/dcp ꔷ 888.327.5596