395

457 Governmental Rollover In

STATE OF HAWAII ISLAND $AVINGS PLAN
Instructions  Complete this form in its entirety.
 Gather the appropriate documentation as requested in the 'Required Information' section of this form.
 Mail or fax this completed form and documentation as instructed below.
 Contact your previous recordkeeper or plan sponsor to initiate a disbursement from your previous account to
Prudential.
Form and You should use this form if you want to roll over eligible money to your current account with Prudential. Please
Check complete using blue or black ink.
Direction Keep a copy of this form for your records. All checks, whether sent by you or your prior employer’s plan, should be
payable to ‘Prudential for the benefit of (participant’s name)’ and should also include the last 4 digits of the individuals
social security number. Any check should be mailed to:

Prudential
30 Scranton Office Park For Assistance
Scranton PA 18507-1789 Call 1-888-71-ALOHA
Fax: 1-866-439-8602 Say “consolidate”

Note: Receipt of the completed form is required within 30 days of the receipt of check. Failure to send us the
completed form may cause the check to be returned.

About To ensure proper and timely processing, please complete all fields below.
You Prudential Plan number Sub plan number 000001 State of Hawaii 000004 County of Maui
000002 County of Hawaii 000005 County of Hawaii Water District
3 0 0 4 1 1
└──┴──┴──┴──┴──┴──┘ └──┴──┴──┴──┴──┴──┘ 000003 County of Kauai 000006 Waialae Charter School

Social Security number Daytime telephone number

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area code

First name MI Last name

└──┴──┴──┴──┴──┴──┴──┴──┴──┴──┘ └──┘ └──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┘

Address
└──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┘

City State ZIP code

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Date of birth Gender Original date employed

└──┴──┘└──┴──┘└──┴──┴──┴──┘ └──┘ M └──┘ F └──┴──┘└──┴──┘└──┴──┴──┴──┘

month day year month day year

Ed. 1/2016 Important information continued and signature required on the following pages
 To ensure proper and timely processing, please complete all fields below. You must include a copy of a
Prior
statement from your prior retirement plan provider.
Retirement
Plan Prior retirement plan provider name
Provider └──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┘
and Plan
Information Prior plan account number └──┴──┴──┴──┴──┴──┴──┴──┴──┘
Prior retirement plan provider address
└──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┘
City State ZIP code

└──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┴──┘ └──┴──┘ └──┴──┴──┴──┴──┘-└──┴──┴──┴──┘

Prior retirement plan provider daytime telephone number

└──┴──┴──┘-└──┴──┴──┘-└──┴──┴──┴──┘
area code

Previous retirement plan name________________________________________________________________

What type of plan are you rolling/transferring FROM?  401(k)  401(a)  403(a)
 403(b)  IRA  Governmental 457(b)
 Simplified Employee Pension (SEP) Plan
(After-tax contributions are not eligible for rollover into this plan.)

Please liquidate and rollover/transfer:

 Total Account Value OR $ └──┴──┴──┘,└──┴──┴──┘.00
If you are enrolled in the Plan and you have not made a rollover investment election by the time your rollover is
Rollover
processed, your rollover contribution will be invested in the same allocation as your employee contributions, otherwise
Allocation it will be invested according to your current allocation. If you are not enrolled in the Plan, your rollover contribution will
Information be invested in the default investment option selected by your Plan.

If you wish to change your investment elections or transfer funds (if allowed under your plan), you can do so by calling
Prudential toll-free at the number on the first page or go online at www.prudential.com/online/retirement.

Required In order for your rollover to be approved, please be sure to submit proof to ensure the assets are acceptable and the
plan satisfies the Code Sections indicated.
Information
You will be required to provide the following documentation from the distributing retirement plan or IRA.

 A copy of a statement from the distributing plan or carrier that includes the plan name and identifies the type of
plan (i.e., 401(a), 401(k) etc.),
OR

 A letter from the distributing plan or plan representative stating the plan is qualified under the applicable section of
the Internal Revenue Code, or a copy of the plan’s most recent determination letter or opinion letter.

Important information continued and signature required on the following pages

Social Security Number_______________________

 Minimum I understand that if I am age 70 ½ or older, the distributing provider is required to process the Required Minimum
Distribution Distribution before these funds are rolled over to Prudential. I further understand that I need to direct the prior provider
Information to distribute my Required Minimum Distribution prior to processing this rollover.

Disclosures If your transaction includes after-tax dollars, your current provider or custodian needs to provide the amount of the
after-tax dollars along with the check, otherwise the entire amount will be applied as before-tax. Not all plans accept
rollovers/transfers of after-tax.

Your I, the Plan participant, certify that all information on this form is accurate. I also certify that this transaction was
Authorization distributed from a plan intended to satisfy the requirements of I.R.C. § 401(a), 403(a), 403(b), 457 (governmental only),
or an IRA established pursuant to IRC § 408 and, which to the best of my knowledge, does satisfy them.

I additionally certify that this distribution can be rolled over into my account with Prudential because it:

1) is not one of a series of substantially equal periodic payments (not less frequently than annually) distributed over my
life or life expectancy (or the joint lives [or joint life expectancies] of me and my beneficiary) or over a period equal to
or greater than 10 years,
2) was received by me not more than 60 days before the date of the rollover to the Plan,
3) would be includible in gross income if not rolled over in its entirety, unless after-tax contributions, which have been
previously taxed.
4) does not represent a Required Minimum Distribution, a hardship distribution, or a corrective distribution (for example:
corrections of elective deferrals or elective contributions, etc.), and
5) was distributed to me as an employee (not as a beneficiary) or as a surviving spouse.

X Date
Participant’s/Account Owner’s signature

Social Security Number_______________________