Application for Surviving Spouse Pension

APPLICATION FOR SURVIVING SPOUSE/ PARTNER PENSION FROM THE PENSION PLAN

Complete this Application for Surviving Spouse/Partner Pension from the Pension Plan if you are the spouse or qualified domestic partner of a deceased Pension Plan member in order to commence a Surviving Spouse/Partner Pension upon the death of the member. Unless already on file with Pension Fund, you must also complete and return with this Application a Beneficiary Verification Form and supporting documentation.
A Surviving Spouse/Partner Pension is an amount equal to 50% of the member's Age Retirement Pension. However, your Surviving Spouse/Partner Pension may be higher if the member elected to receive a reduced Age Retirement Pension in order for you to receive a 75% or 100% Surviving Spouse/Partner Pension, and the member had already commenced his or her Age Retirement Pension at the time of the member's death. Your Surviving Spouse/Partner Pension will also be increased by special apportionments that may be awarded from time to time by the Pension Fund Board.
If you married the member after the member retired and commenced his or her pension under the Pension Plan, then the marriage must have taken place at least 12 months prior to the member's death for you to be eligible to receive a Surviving Spouse/Partner Pension. If you entered into a qualified domestic partnership after the member retired and commenced his or her pension under the Pension Plan, then an Affidavit of Qualified Domestic Partnership must be effective for at least 24 months prior to the member's death for you to be eligible to receive a Surviving Spouse/Partner Pension.
Your Surviving Spouse/Partner Pension will be paid monthly for your life commencing on the member's date of death if the member died before he or she began to receive a pension under the Pension Plan or the first day of the month after the member's date of death if the member died while receiving a pension under the Pension Plan. The Surviving Spouse/Partner Pension will not be paid for any period preceding the date of this Application by more than three months.
- PLEASE TYPE OR PRINT CLEARLY –
I. SURVIVING SPOUSE/PARTNER INFORMATION

Spouse/Partner Name (first)

(middle)

(last/family name)

Last four digits of Social Security No./ITIN __ __ __ __ Date of Birth ______/______/______ Date of Marriage/Partnership______/______/______

Check here if there has been a change to your contact information on file.

Home Address

City

State

Country

Zip Code _______-

Home Phone Number (

)

Work Phone Number (

)

Cell Phone Number (

)

E-Mail Address ________________________________________________________________ Citizenship

Member Name

(first)

(middle)

(last/family name)

Member Ref. No.

II. FEDERAL AND STATE INCOME TAX WITHHOLDING [SUBSTITUTE W-4P]

Pension Fund will withhold on the distributions made to you from the Pension Plan as if you are married claiming three withholding allowances, unless you elect more or less withholding from your distributions (check one only):

Do NOT withhold federal income tax from any distributions.

Withhold federal income tax from each distribution in accordance with the following:

 Total number of allowances you are claiming for withholding from each distribution

.

 Marital status: Single Married Married, but withhold at higher single rate.

 Additional dollar amount, if any, you want withheld from each distribution: $

..

(Note: You cannot enter an additional amount without entering the number of allowances above).

Withholding will apply only to the portion of your distribution that is included in your income.

Your election will remain in effect until you submit a new Substitute Form W-4P making a new election. You may submit a new Substitute Form W-4P at any time, and it will be effective the first day of the next month that falls at least 30 days after the completed Substitute Form W-4P is received by Pension Fund. If you elect not to have withholding apply to your distributions, or if you do not have enough federal income tax withheld from your distributions, you may be responsible for payment of estimated tax.

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If the social security number you provided to Pension Fund is not correct, Pension Fund is required to withhold taxes on your distributions as if you are single claiming zero withholding allowances, even if you elected to have no withholding.
Unless you have a current state income tax withholding election in place, you will need to complete a state tax withholding certificate for your state of residence. If you live in a state that mandates state income tax withholding, Pension Fund will withhold the required amount. Please indicate your state of tax residence (if different than your home address in Section I) __________________________. For more information regarding the withholding requirements of your state of residence, see www.pensionfund.org.

III. PAYMENT OF SURVIVING SPOUSE/PARTNER PENSION

I understand that my Surviving Spouse/Partner Pension will be direct deposited by ACH into my bank account. Complete the following information and attach a "void" check to this Application:

Name of Bank

Mailing Address of Bank

City

State

Country

Zip Code ________-

Phone Number (_______)

Your Account Number

Bank Routing Number ____________________________ Checking Savings

IV. HEALTH CARE COVERAGE

If you are a current participant in the Christian Church (Disciples of Christ) Health Care Plan on the day prior to the member's death, please complete this Section.
I wish to discontinue coverage under the Health Care Plan at the end of the month in which the member died.
I wish to continue individual coverage under the Health Care Plan and make the following coverage elections:
Elect one: Medicare Basic Medicare Basic with prescriptions Medicare Plus Medicare Plus with prescriptions
I authorize Pension Fund to withhold the monthly premium from my Pension Plan distributions (premiums are paid on an after-tax basis).

V. SURVIVING SPOUSE/PARTNER CERTIFICATION AND SIGNATURE

By signing this Application, I make the following certifications:
• I certify that the information provided on this Application is accurate. I agree that I will timely notify Pension Fund of any changes to the information provided on this Application.
• Unless already provided to Pension Fund, I have returned a completed Beneficiary Verification Form and supporting documentation with this Application. I certify that I have identified all surviving children of the member of whom I am aware on the Beneficiary Verification Form. I understand that the member's surviving children may also be entitled to survivor benefits under the Pension Plan, and that I should contact Pension Fund for information on these benefits.
• I understand that, if applicable, an Affidavit of Qualified Domestic Partnership with supporting documentation must be on file with Pension Fund before the death of the member in order to be eligible for a Surviving Spouse/Partner Pension. I further understand that if the member has already commenced a pension or disability benefit under the Pension Plan as of the effective date of an Affidavit of Qualified Domestic Partnership, a Surviving Spouse/Partner Pension will be payable only if the Affidavit of Qualified Domestic Partnership has been effective for at least 24 months before the death of the member.
• I understand that the personal information provided on this Application will be used by Pension Fund to process my elections and to provide member services to me under the Pension Plan.
• I understand that if the member died while actively participating in the Pension Plan or while receiving a disability benefit under the Pension Plan, I may also be eligible for a Salary Continuation Death Benefit from the Pension Plan. I further understand that if the member was actively participating in the Pension Plan at his or her retirement date and was receiving a pension when he or she died, I may also be eligible for a Pensioner Death

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Benefit from the Pension Plan. I understand that I should contact Pension Fund for more information on these benefits.

Surviving Spouse/Partner Signature

Date ________/________/________

Pension Fund of the Christian Church P.O. Box 6251, Indianapolis, Indiana 46206-6251 Toll Free Phone: 1.866.495.7322 • Phone: 317.634.4504 • Fax: 317.634.4071 E-mail: [email protected] • Website: www.pensionfund.org

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