Brewer Enrollment - Web Book - 2024 - Flipbook - Page 26
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
2.
Date of Hire
Account to be rolled over/transferred into the Brewer Orthodontics PLLC 401(k) Profit Sharing Plan
I authorize the Custodian/Trustee of my IRA, or current Employer Retirement plan, to send the assets indicated below directly to my account with
the Brewer Orthodontics PLLC 401(k) Profit Sharing Plan administered by Certified Benefits Corp, Third Party Administrator (TPA).
Name of Present Custodian or Employer Plan
Address
City
Phone Number
Current Account Number(s)
This rollover/transfer is from:
ò
401(k)
ò
403(b)
ò
State
401(a)
ò
457
ò
Zip
Traditional IRA
*Please attach a copy of your most recent statement from the IRA or Retirement account described in Section 2.
3.
Payment Information and Instructions
w
I request the assistance of Certified Benefits Corp with the transfer/rollover of my vested benefit from the account
listed above; please immediately liquidate all assets and send the cash proceeds.
Make check payable to
