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HomeMy WebLinkAbout104-25 RESOLUTION113 West Mountain Street Fayetteville, AR 72701 (479) 575-8323 Resolution: 104-25 File Number: 2025-500 FAYETTEVILLE ANIMAL SHELTER DONATION (SUSAN SHELTON): A RESOLUTION TO AUTHORIZE THE MAYOR TO ACCEPT THE LIFE INSURANCE PROCEEDS OF SUSAN SHELTON, AND TO RECOGNIZE SUSAN SHELTON FOR HER DONATION TO THE FAYETTEVILLE ANIMAL SHELTER WHEREAS, Susan Shelton, a resident of the City of Fayetteville, passed away in February 2025, having named the Fayetteville Animal Shelter as the beneficiary of her life insurance policy; and WHEREAS, the insurance company requires a resolution authorizing a representative of the City of Fayetteville to accept the life insurance proceeds on behalf of the City and the Fayetteville Animal Shelter. NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FAYETTEVILLE, ARKANSAS: Section 1: That the City Council of the City of Fayetteville, Arkansas hereby authorizes Mayor Rawn to execute any documents necessary to accept the proceeds of Susan Shelton's life insurance policy on behalf of the City of Fayetteville and the Fayetteville Animal Shelter. Section 2: That the City Council of the City of Fayetteville, Arkansas hereby expresses its sincere appreciation to Susan Shelton for her generosity in donating the proceeds of her life insurance policy to the Fayetteville Animal Shelter. PASSED and APPROVED on May 6, 2025 Approved: Molly Rawn, Mayor Attest: �'n�'CiON GOA• Kara Paxton, City Clerk Treasurer Page 1 CITY OF FAYETTEVILLE ARKANSAS MEETING OF MAY 6, 2025 CITY COUNCIL MEMO TO: Mayor Rawn and City Council THRU: Kit Williams, City Attorney Blake Pennington, Assistant City Attorney FROM: Hannah Hungate, Assistant City Attorney SUBJECT: FAYETTEVILLE ANIMAL SHELTER DONATION (SUSAN SHELTON): RECOMMENDATION: 2025-500 The City Attorney's Office recommends that City Council authorize Mayor Rawn to accept, on behalf of the City, life insurance proceeds donated by Susan Shelton to the Fayetteville Animal Shelter. BACKGROUND: Susan Shelton, a resident of the City of Fayetteville and longtime music and animal lover, passed away in February 2025. Upon her passing, Nationwide Insurance Company contacted the Fayetteville Animal Shelter to notify them that Ms. Shelton had named the Fayetteville Animal Shelter as the beneficiary of her life insurance policy. In order to claim the life insurance proceeds, the City must submit to Nationwide a completed claim form, a death certificate, and a corporate resolution which designates a City representative to accept the proceeds on behalf of the City and the Fayetteville Animal Shelter. DISCUSSION: To claim the life insurance proceeds donated to the Fayetteville Animal Shelter by Ms. Shelton, the City Council must pass a resolution authorizing the Mayor to accept the proceeds on behalf of the City of Fayetteville and Fayetteville Animal Shelter. A copy of the Claim Form to be executed by Mayor Rawn upon resolution by the City Council is attached. BUDGET/STAFF IMPACT: N/A ATTACHMENTS: SRF (#3) , Beneficiary Claim Form (#4), CFO - Staff Memo (#5) Mailing address: 113 W. Mountain Street www.fayetteville-ar.gov Fayetteville, AR 72701 == City of Fayetteville, Arkansas y 113 West Mountain Street Fayetteville, AR 72701 (479)575-8323 - Legislation Text File #: 2025-500 FAYETTEVILLE ANIMAL SHELTER DONATION (SUSAN SHELTON): A RESOLUTION TO AUTHORIZE THE MAYOR TO ACCEPT THE LIFE INSURANCE PROCEEDS OF SUSAN SHELTON, AND TO RECOGNIZE SUSAN SHELTON FOR HER DONATION TO THE FAYETTEVILLE ANIMAL SHELTER WHEREAS, Susan Shelton, a resident of the City of Fayetteville, passed away in February 2025, having named the Fayetteville Animal Shelter as the beneficiary of her life insurance policy; and WHEREAS, the insurance company requires a resolution authorizing a representative of the City of Fayetteville to accept the life insurance proceeds on behalf of the City and the Fayetteville Animal Shelter. NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FAYETTEVILLE, ARKANSAS: Section 1: That the City Council of the City of Fayetteville, Arkansas hereby authorizes Mayor Rawn to execute any documents necessary to accept the proceeds of Susan Shelton's life insurance policy on behalf of the City of Fayetteville and the Fayetteville Animal Shelter. Section 2: That the City Council of the City of Fayetteville, Arkansas hereby expresses its sincere appreciation to Susan Shelton for her generosity in donating the proceeds of her life insurance policy to the Fayetteville Animal Shelter. Page 1 Hannah Hungate Submitted By City of Fayetteville Staff Review Form Item ID 5/6/2025 City Council Meeting Date - Agenda Item Only N/A for Non -Agenda Item 4/11/2025 CITY ATTORNEY (021) Submitted Date Division / Department Action Recommendation: The City Attorney's Office recommends that City Council authorize Mayor Rawn to accept, on behalf of the City, life insurance proceeds donated by Susan Shelton to the Fayetteville Animal Shelter. Account Number Project Number Budgeted Item? No Does item have a direct cost? No Is a Budget Adjustment attached? No Purchase Order Number: Change Order Number: Original Contract Number: Comments: Budget Impact: Fund Project Title Total Amended Budget $ - Expenses (Actual+Encum) $ - Available Budget Item Cost $ - Budget Adjustment $ - Remaining Budget V20221130 Previous Ordinance or Resolution # Approval Date: 1 Annuity Beneficiary Claim Form Nationwide Nationwide Life Insurance Company - Nationwide Life and Annuity Insurance Company PO Box 182021, Columbus, OH 43218-2021 Phone: 800-848-6331 - Fax: 888-634-4472 - nationwide.com - Print clearly - Include a copy of the certified death certificate - Questions? Call 800-848-6331 - Want a claim status? Provide an email address and we'll send a status upon request. 1. Contract Owner and Beneficiary Information Decedent (Deceased Member): Name: Annuity Contract Number: Individual Beneficiary claiming the annuity benefit (One per form. For estate/trust, enter address, phone and email below then skip to Estate/Trust claiming the annuity benefit): Name: IMPORTANT: If you are a surviving spouse you must also complete Section 2 SSN/TIN: Date of Birth: Address: City: State: Zip: Phone: Email: Nationwide strives to provide excellent customer service to our Members. By providing your telephone number, you authorize the Nationwide Family of Companies to contact you via telephone using automated technology to assist you with your account. Estate/Trust claiming the annuity benefit: Please return a copy of the Trust Certification Form (for trust) or letter of testamentary/administration (for Estate) with this form. Name of Estate or Trust: Executors)/Trustee(s) Name: TIN/EIN/SSN for Estate or Trust: Please make sure to review the Important Details and Disclosures on pages 9-12. 2. Spousal Elections (if applicable) Please make sure to review the Important Details and Disclosures related to each distribution option on pages 9-12 before making your election. As a SPOUSE of the decedent you have the following two elections available, please choose one: ❑ Option 1: 1 elect to re -register the annuity contract and become the contract owner If your contract has spousal protection associated with the death benefit. election of Option 1 will allow the surviving spouse to both continue the annuity contract and receive any applicable adjustments to the contract value. IMPORTANT: Required actions: Name beneficiaries (in Section 6) and sign (in Section 8 (NY Residents Only) and Section 10) The Annuity Commencement Date (ACD) is the date when annuity payments will begin. When you become the new owner, the date will be changed according to the terms of the contract. If your annuity contract allows, you can change the ACID before payouts begin. We'll let you know if any action is required. NOTE: If a spousal transfer, one-time or systematic withdrawal is wanted. additional paperwork needs to be completed and cannot be indicated on this form. 1 Option 2: 1 elect to be treated as a beneficiary AND will choose a distribution (claim) option on the next page in section 3. IMPORTANT: Required actions: Choose a distribution option (in Section 3) The Internal Revenue Service requires you to make an election by a certain date. If this is a Non -Qualified annuity. this election is only available for 1 year from the date of death. If this is a Qualified annuity, this election is available until 12/31 of the year following the owner's date of death. If we receive your claim form after the allowable date, we will default to Option 1. AAF-0107AO.26 Page 1 of 12 (11/2024) 3. Select an Option This section is REQUIRED to be completed by any spouse beneficiary who elected Option 2 in Section 2 of this form and for all non -spouse beneficiaries. Please make sure to review the Important Details and Disclosures related to each distribution option on pages 9-12 before making your election. ❑ Option 3: Select 5-Year or 10-Year Delayed Distribution Option (Complete 3a or 3b below) Claimant will become the Beneficial Owner. Withdrawals may be taken any time during the 5 or 10 year period. Withdrawals may also be required to be taken annually (see 3b for details). To take a one-time or scheduled withdrawal now, please contact us for a distribution form. The contract must be fully liquidated by the end of the 5 or 10 year period (based on your contract type). Nationwide will contact you for distribution instructions prior to the end of your 5 or 10 year term. If you choose an option not available to you, we will default your election to the appropriate option. 3a. For Non -Qualified Contracts ❑ 5-Year Delayed Distribution Option (To take a one-time or scheduled withdrawal now, please contact us for distribution form) Required actions: Name beneficiaries (in Section 6) and sign (in Section 8 (NY Residents Only) and Section 10). 3b. For Qualified Contracts Ll 5-Year Delayed Distribution Option (You may elect this option if the decedent passed on or before December 31, 2019) (To take a one-time or scheduled withdrawal now, please contact us for distribution form) IMPORTANT: If the decedent reached their Required Beginning Date (RBD), this option is not available and you must elect Life Expectancy Distribution Option (5b). Required actions: Name beneficiaries (in Section 6) and sign (in Section 8 (NY Residents Only) and Section 10) ❑ 10-Year Delayed Distribution Option (You may elect this option if the decedent passed on or after January 1, 2020) (To take a one-time or scheduled withdrawal now, please contact us for distribution form) IMPORTANT: if the decedent reached their Required Beginning Date (RBD) the Beneficial Owner under this option must: (1) withdraw an amount equal to the decedent's Required Minimum Distribution (RMD) amount in the year of the decedent's death. Please check the box below to authorize the one-time distribution immediately. (2) withdraw an amount each year after the decedent's death, at least annually, based on the IRS's At Least As Rapidly (ALAR) Rule using the IRS's Life Expectancy Table. ❑ I authorize a one-time distribution equal to the decedent's RMD amount The distribution will occur immediately and will be tax reportable to the Beneficial Owner. If you are the sole beneficiary, we will disburse the full RMD amount. If there are multiple beneficiaries, we'll disburse your portion of the RMD amount. Required actions if decedent reached their RBD: Enter withdrawal frequency and start date (below), to aggregate or receive payments (below), choose payment method (in Section 4), enter tax withholdings (in Section 5), Name beneficiaries (in Section 6) and sign (in Section 8 (NY Residents Only) and Section 10) Required actions if decedent DID NOT reach their RBD: Name beneficiaries (in Section 6) and sign (in Section 8 (NY Residents Only) and Section 10) ❑ I want to aggregate the Required Minimum Distribution I own more than one beneficially owned annuity contract and I intend to satisfy my distribution requirements by taking withdrawals from another contract. By checking this box. I certify that I understand it is my responsibility to inform Nationwide if I ever decide not to aggregate and need to begin taking distributions from this contract. Nationwide will not be responsible for any federal tax penalties that I incur as a result of my failure to notify Nationwide. ❑ 1 want to receive payments under At Least As Rapidly (ALAR) Rules IMPORTANT: If you leave this section blank, we'll default to an annual distribution date of 12/1 the year after the decedent passed. Elect Frequency: ❑ Monthly ❑ Quarterly ❑ Semi-annually ❑ Annually Enter Start Date: (MM/DD/YYYY) AAF-0107AO.26 Page 2 of 12 (11/2024) 3. Select an Option (continued) 0 Option 4: Receive Guaranteed Income (Annuitization) Convert the annuity into a series of periodic payments determined by the beneficiary. Once annuitization begins the option becomes irrevocable and additional withdrawals are not available. Certain restrictions apply. Required actions: Sign (in Section 8 (NY Residents Only) and Section 10) and complete Deferred Annuitization Election (DAE) form. We'll send the DAE form to you when we receive your completed claim form, but it's also available upon request to review prior to the submission of this form. Call 800-452-7126 for assistance. ❑ Option 5: Select Life Expectancy Distribution Option (Complete 5a or 5b below) Claimant will become the Beneficial Owner and will receive payments based on the beneficial owner's life expectancy. See pages 9-12 to review time limits & other details before you make your election. ❑ 5a. For Non -Qualified Contracts WARNING: Distributions must be taken at least annually and cannot be stopped once they begin. Required actions: Enter withdrawal frequency & start date (below), choose payment method (in Section 4), enter tax withholdings (in Section 5), name beneficiaries (in Section 6) and sign (in Section 8 (NY Residents Only) and Section 10). Withdrawal Frequency and Start Date Elect Frequency (if left blank, we'll default to Annually): F— Monthly ❑ Quarterly ❑ Semi-annually ❑ Annually Enter Start Date: (MM/DD/YYYY) IMPORTANT: if you leave the start date blank or enter a date after the RBD. Nationwide will default to the Required Beginning Date (RBD). which is 1 year from the date of death. ❑ 5b. For Qualified Contracts (When the decedent passed on or after January 1, 2020. this option is only available when the beneficiary is an Eligible Designated Beneficiary) WARNING: Distributions of the Required Minimum Distribution must be taken at least annually. Any missed or delayed distributions may be subject to a federal excise tax penalty. I am an Eligible Designated Beneficiary and can elect the Life Expectancy Distribution Option because (check which eligibility requirement applies): ❑ I am the surviving spouse of the decedent ❑ I am a minor child of the decedent2 ❑ I am a disabled individual (documentation required) ❑ I am a chronically ill individual (documentation required) ❑ I am a non -spouse adult who is older than. or not more than 10 years younger than the decedent Required actions: Select eligibility requirement (above), choose to aggregate or receive payments (below), enter withdrawal frequency & start date (below, if applicable), choose payment method (in Section 4), enter tax withholdings (in Section 5), name beneficiaries (in Section 6) and sign (in Section 8 (NY Residents Only) and Section 10). ❑ I want to aggregate the Required Minimum Distribution I own more than one beneficially owned annuity contract and I intend to satisfy my distribution requirements by taking withdrawals from another contract. By checking this box, I certify that I understand it is my responsibility to inform Nationwide if I ever decide not to aggregate and need to begin taking distributions from this contract. Nationwide will not be responsible for any federal tax penalties that I incur as a result of my failure to notify Nationwide. ❑ I want to receive Life Expectancy payments If you've elected to receive payments, you must also elect both a frequency and start date' Elect Frequency: ❑ Monthly ❑ Quarterly ❑ Semi-annually ❑ Annually Enter Start Date: (MM/DD/YYYY) If you don't elect a frequency, we'll default to an annual distribution. If the start date provided is after the Required Beginning Date (12/31 in the year following the date of death). Nationwide will default to an appropriate start date which ensures distribution on or before the Required Beginning Date. i Make sure to review the information regarding payments to Minors in the Important Details and Disclosures on pages 9-12. AAF-0107AO.26 Page 3 of 12 (11/2024) 3. Select an Option (continued) ❑ Option 6: Take a lump sum withdrawal Receive the full value of the death benefit by direct deposit or check (made payable to the beneficiary). May result in a taxable event. Please review Important Details and Disclosures on pages 9-12 before making your election. Required actions: Choose payment method (in Section 4), enter tax withholdings (in Section 5), and sign (in Section 8 (NY Residents Only) and Section 10). 4. Select a Payment Method (Please select one of the five options below) ❑ 4a. Direct Deposit You are authorizing a one-time or recurring Automated Clearing House (ACH) credits (direct deposits) to the bank account provided on this form. Funds must be deposited to a U. S. Institution. Please see Important Disclosures on Pages 9-12. Account Type' (Must select one): ❑ Checking ❑ Savings (Provide account information below) 'If you don't provide an account type, we'll default to checking. Bank Account Holder Name (must be Payee): Financial Institution Name: Transit/ABA Routing Number: Account Number: ❑ 4b. Digital Payment via the J.P. Morgan Concourse Platform (Can ONLY begin with O, 1, 2 or 3) This payment option is only available for payments made to you for $50,000 or less. The digital payment option does not require you to provide banking information directly to Nationwide. Payment will be facilitated via a third party digital payment platform called J.P. Morgan Concourse.2 Within one to two business days from the date your claim is processed, you will receive an email from Nationwide (donotreply-4,jpmorgan.com) to facilitate your payment. Depending on your withdrawal amount, you may be able to select from several payment acceptance methods (such as ACH or Zelle). Additional account information will be entered into the J.P. Morgan Concourse platform. First-time users will be prompted to register prior to collecting payments. Payments must be accepted within seven business days of receipt. If you do not accept your digital payment, a check will be mailed to your address of record. Email Address (Required): To protect against fraud, we may request additional information to verify your email address. 2The digital payment platform is powered by J.P. Morgan Chase. J.P. Morgan Chase will not distribute or disseminate any information provided for purposes other than facilitating your digital payment. By selecting this option, you will be prompted to register to accept your payment, but no J.P. Morgan Chase account will be created without your consent. ❑ 4c. Mail a check to the address provided in Section 1 (This is the default option if you don't choose a payment method) ❑ 4d. Mail a check to another address (for a lump sum payment only) ❑ Check this box if sending to a brokerage or money market account Street Address: City: State Zip: ❑ 4e. Send my check to another Financial Institution or open a new Nationwide annuity (for lump sum payment only) To switch to another Financial Institution, provide the information below. Overnight service is not available. IMPORTANT: In order for us to send a check to another Financial Institution, we will require a letter of acceptance and all other applicable transfer documents from the receiving company. The Letter of acceptance must also confirm your account with the receiving company and that they will accept the funds as a non-taxable transfer. Without a letter of acceptance from the receiving company, the transfer will be taxable. I-1 I authorize a one-time distribution equal to the decedent's RMD amount to be mailed to my address in Section 1. Any tax withholding in Section 5 will only apply to this distribution. The remainder of the proceeds will be sent to the Carrier listed below. Carrier Name: Carrier Address: City: AAF-0107AO.26 Page 4 of 12 ,icrle NUrT)i)er. State: Zip: (11/2024) S. Enter Tax Withholdings Nationwide will withhold 10% federal tax and any required Resident State tax, unless designated differently below. Total federal and state tax withholding cannot exceed 100%. See Important Details and Disclosures on Pages 9-12 for more information. Federal Tax Withholding I elect: ❑ No federal income tax withheld from each of my payments If you wish to have federal income tax withheld, that is different than the default withholding rate, then the W-4R federal tax withholding form is required. The current W-4R federal tax withholding form can be found on the IRS website at IRS.gov. Taxes will only be withheld and reported to the designated beneficiary claiming the annuity benefit. If we don't receive the form and you have not elected (No federal income tax withheld), Nationwide will default to withholding taxes based on the current IRC withholding rules. The default withholding rate is 10% (20% for eligible rollovers). IMPORTANT: Distributions you receive from qualified retirement plans (for example, 401(k) plans and section 457(b) plans maintained by a governmental employer) or tax-sheltered annuities that are eligible to be rolled over to an IRA or qualified plan are subject to a 20% default rate of withholding on the taxable amount of the distribution. You may not elect a withholding rate of less than the 20% or elect to have no withholding; however, you may elect a higher rate, which would require completing a W-4R federal tax withholding form. Please refer to the general instructions on the W-4R federal tax withholding form for more information. You may be subject to tax penalties if your estimated tax payments and tax withheld are not adequate. It is always recommended to consult with a tax advisor on your specific circumstance. State Tax Withholding % Resident State: (whole percentages are required) To avoid mandatory state withholding. for those states that require it, you MUST provide a completed state tax form (located on the State's website). Nationwide does not provide these forms. Please make sure to review the Important Details and Disclosures on pages 9-12. S. Enter New Beneficiaries (For Distribution Options 1, 3, or 5) The beneficiary making the claim must enter new beneficiaries if you are choosing to: re -register (Option 1), elect 5-Year or 10-Year delayed distribution options (Option 3) or take life expectancy distributions (Option 5). Allocation(s) must equal 100% for primary beneficiaries. Allocation(s) must also equal 100% for contingent beneficiaries. No decimals permitted. IMPORTANT: Use the Additional Beneficiaries Form if you have more than 3 primaries or 2 contingents. If Allocation is left blank, we'll assume equal allocations for all beneficiaries listed. For estates/trusts: If the beneficial owner is an estate/trust you can skip this section, because we'll list the estate/trust as the beneficiary. 6a. Primary Beneficiaries: ❑ Pay all Primary Beneficiaries Equally (leave Allocation fields blank) 1. Full Legal Name: Relationship to Insured (Required): SSN: Street Address (❑ Same as Owner): City: Email: 2. Full Legal Name: Relationship to Insured (Required): SSN: Street Address (❑ Same as Owner): City: Email: AAF-0107AO.26 Allocation (whole % only): % Date of Birth: State: ZIP: Phone: Allocation (whole % only): % Date of Birth: Page 5 of 12 State: Phone: ZIP: (11/2024) 6. Enter New Beneficiaries (For Distribution Options 1, 3, or 5) (continued) 3. Full Legal Name: Relationship to Insured (Required): SSN: Street Address (❑ Same as Owner): City: Email: 6b. Contingent Beneficiaries: I. Full Legal Narne: Relationship to Insured (Required): SSN: Street Address (❑ Same as Owner): City: Email: 2. Full Legal Name: Relationship to Insured (Required): SSN: Street Address (❑ Same as Owner): City: Date of Birth: State: Allocation (whole % only): % ZIP: Phone: Allocation (whole % only): % Date of Birth: State: ZIP: Phone: Date of Birth: State: Allocation (whole % only): % Ema i Phone: 7. State Fraud Disclosures ZIP: Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance. is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Alaska: Any person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law. Connecticut, Georgia, Hawaii, Illinois, Iowa, Massachusetts, Michigan, Mississippi, Missouri, Montana, Nebraska, South Carolina, South Dakota, Utah, Vermont, Virgin Islands, Wisconsin and Wyoming: Any person who submits an application or a claim containing a false or deceptive statement. and does so with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, may be guilty of insurance fraud. Arkansas, Rhode Island, Texas and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado: Important Notice: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines. denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false. incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department or regulatory agencies. AAF-0107AO.26 Page 6 of 12 (11/2024) 7. State Fraud Disclosures (continued) Delaware, Idaho, Indiana and Oklahoma: Any person who Knowingly and with intent to injure, aefraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. District of Columbia Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure. defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kansas, Nevada, North Carolina and North Dakota: Any person who submits an application or a claim containing a false or deceptive statement, and does so with intent to defraud or knowing that he/she is facilitating a fraud against an insurer. may be guilty of insurance fraud. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Louisiana: Any person who knowingly presents false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment. fines and denial of insurance benefits. Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false. incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. Ohio: Any person who. with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oregon: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact. may be violating state law. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit. or presents more than one claim for the same damage or loss, shall incur a felony and. upon conviction. shall be sanctioned for each violation with the penalty of a fine of not less then five thousand (5,000) dollars and not more than ten thousand (10.000) dollars, or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (S) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. AAF-0107AO.26 Page 7 of 12 (11/2024) 8. Acknowledge New York Fraud Statement (required for residents of New York) NOTE: Signature in this section is a requirement for all claim forms, when the beneficiary is a resident of New York. The beneficiary must also sign in Section 10. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading. information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Beneficiary/Executor/Trustee Signature(s): Signature(s): 9. Certify Taxpayer ID I certify that under penalties of perjury that: Date: Date: 1. The Taxpayer Identification Number or Social Security Number listed on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. 1 am not subject to backup withholding because: a. I am exempt from backup withholding, or b. I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or c. The Internal Revenue Service has notified me that I am no longer subject to backup withholding, and 3. 1 am a U.S. citizen or other U.S. person, and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. (FATCA does not apply as this is a U.S. account) You must cross out item (2) if you have been notified by the IRS that you are currently subject to backup withholding because of failure to report interest or dividends on your tax return. 10. Sign and Date The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Beneficiary: Full Name (please print): Signature: SSN/TIN (required) Executor/Trustee (if applicable): Full Name (please print): Signature: Signature Co-Executor/Co-Trustee: TIN/EIN for Estate or Trust (required)': Date: Date: IMPORTANT: If the contract is Corporate -Owned or Collaterally Assigned, we require an officer signature & a corporate resolution indicating the officer's signing authority. If the beneficiary is a trust, we require a trust certification form or copy of the Trust agreement. If the beneficiary is an Estate, we require letters of administration or testamentary. ' Not the SSN for the Executor or Trustee Nationwide, the Nationwide N and Eagle is a service marks of Nationwide Mutual Insurance company_ :f 2024 Nationwide ►L�i)<L�rlsex�7 Page 8 of 12 (11/2024) r� 1 Annuity Beneficiary Claim Form Nationwide' Important Details and Disclosures PLEASE RETAIN THIS PORTION OF THE FORM FOR YOUR RECORDS. Submit to Nationwide ®Submit by regular mail: Nationwide Life Insurance Company PO Box 182021 Columbus, OH 43218-2021 Submit by Fax: 888-634-4472 For More Information: Call 800-848-6331 General Information Submit by overnight mail: Nationwide Insurance 1-LC-F4 1 Nationwide Plaza Columbus. OH 43215-2239 • Tax disclosure: Federal laws related to these types of contracts are complex and can change. Be sure to consult with a tax advisor, financial professional, or attorney if you have questions. Nationwide doesn't provide tax or legal advice. • To determine if a death benefit is payable based on owner or annuitant death, please contact your advisor or call the number above. • The use of the term Insured on this form is defined as: • For contracts where a death benefit is payable upon the death of the Annuitant, Insured means Annuitant. • For contracts where a death benefit is payable upon the death of the Owner, Insured means Owner. • On Annuitant Driven Contracts, If Owner and Annuitant are NOT the same person: If the owner dies, the contract value, instead of the death benefit, is payable. Because this is not a death benefit claim, any withdrawals may be subject to Contingent Deferred Sales Charges/Surrender Charges, Market Value Adjustment (positive or negative) and/ or recoupment of Purchase Payment Bonus. • On Owner Driven Contracts, if the owner and the annuitant are NOT the same person: If the annuitant dies, the contract owner must name a new annuitant if no contingent annuitant is on the contract. Because this is not a death benefit claim. any withdrawals may be subject to Contingent Deferred Sales Charges/Surrender Charges, Market Value Adjustment (positive or negative) and/or recoupment of Purchase Payment Bonus. • Contingent Deferred Sales Charge (CDSC) and/or Market Value Adjustment (MVA) : Where the Insured dies and a death benefit is payable, CDSC and/or MVA is waived on beneficially owned contracts staying in the same product. If transferring to a new product, check the contract and/or prospectus for how CDSC and MVA (if applicable) will be processed. • Multiple beneficiaries entitled to portion of death benefit: Contract value remains invested according to the decedent owner's instructions until a valid beneficiary claim form is submitted. Once the first claim is received, portions of the contract value will be re -allocated as outlined in the contract and/or prospectus until claims are received from the remaining beneficiaries. Any portion of the contract value invested in a fixed or money market account will not be reallocated. • One beneficiary entitled to death benefit: Contract value remains invested according to decedent owner's instructions. No reallocation will occur unless instructed as allowed within the terms of the contract. • Investment selection: On certain contracts, beneficial owners and the spouse owner will have the option to change investments options if allowed within the terms of the contract. Please contact us to discuss additional options. • Payments to minors: Nationwide will not pay insurance proceeds to minors. A court appointed guardian of the estate, conservator, custodian under a state's Uniform Transfer to Minors Act or a trust typically receive these funds on behalf of a minor. Contact your attorney to discuss the timely availability of monies intended for the minor's benefit. Section 2: Spousal Elections (Options 1 and 2) • Marriage definition: According to the IRS, a spouse is an individual lawfully married to another individual. Relationships that are seen under state law as civil unions, registered domestic partnerships or other, and not as marriages, are not recognized as marriages for federal tax purposes and individuals in these relationships are not entitled to federal tax benefits. • Withdrawals: A re -registered spousal owner may be subject to a 10% early withdrawal federal tax penalty if withdrawals are taken before age 59'/z. • Timely distributions: If the spouse, as beneficial owner, fails to take distributions when required, or adds additional money to the contract, the spouse will be re -registered as the contract owner. Any new deposits will be subject to CDSC as outlined in the contract. AAF-0107AO.26 Page 9 of 12 (11/2024) For Qualified Contracts • No direction on Qualified Plans: If we don't receive direction from a surviving spouse to keep a contract registered as a Qualified Plan, funds for the spouse beneficial owner will be registered as a Nationwide IRA. • RMD for Option 1: If you elect Option 1, you can delay your Required Minimum Distribution (RMD) until you reach the RMD age_ • RMD for Option 2: If you elect Option 2, you can delay your RMD under the Life Expectancy Distribution Option (Option 5) until the decedent owner would have reached the RMD age. For Non -Qualified Contracts Re -registration: Available even when there is more than one beneficiary. The spouse is permitted to re -register only their portion of the contract. Section 3: Distribution Options (Options 3, 4, 5, and 6) General Information • Restrictions: Not all options and features associated with the annuity contract are available to beneficial owners. • Additional deposits: No new deposits are allowed for beneficially owned contracts. • Beneficiary: If new beneficiaries are not named where required, Nationwide will default the beneficiary to the beneficial owner's estate. Option 3: 5-year or 10-Year Delayed Distribution Option • 5-Year Delayed Distribution Option: This option is only available for Non -Qualified contracts or if the decedent in a Qualified contract passed on or before 12/31/2019 and the decedent owner had not reached the RMD age. Withdrawals taken are not subject to the 10% early withdrawal penalty. • 10-Year Delayed Distribution Option: This option is only available for Qualified contracts where the decedent passed on or after January 1, 2020. Withdrawals taken are not subject to the 10% early withdrawal penalty. For Qualified Contracts • Election: The option must be selected by December 31 in the year after the year of death (example: If date of death is 6/1/2025, delay distributions up to 10 years must be selected by 12/31/2026). • If the decedent reached their Required Beginning Date (RBD), the Beneficial Owner under this option must: (1) withdraw an amount equal to the decedent's RMD amount in the year of the decedent's death. (2) withdraw an amount each year after the decedent's death, at least annually. The calculation is based on the longer life expectancy of the beneficial owner or decedent. Decedent's Required Beginning Date (RBD): the date the decedent is required to take their required minimum distribution (RMD), per IRS guidelines • Liquidation: All contract value must be taken by December 31 in the loth year (based on option elected)from the year of death (example: If date of death was 6/1/2025 and a 10 year option was elected, liquidation must be complete by 12/31/2035). Failure to do so may result in tax penalties. For Non -Qualified Contracts • Liquidation: All contract value must be taken by the Sth year from the date of death. (example: If date of death was 6/1/2025, liquidation must be complete by 06/1/2030) Option 4: Receive Guaranteed income (Annuitization) • Availability: Annuitization is not available unless the election is made and payments begin by the required date. • Non -Qualified Contracts: Election of this option must be made and distributions must begin within one year after the decedent's death. (example: If date of death is 6/1/2022, distributions must begin by 5/31/2023). • Qualified Contracts: Election of this option must be made by 12/31 of the year following the decedent's death. When distributions are required to begin will depend on whether the beneficiary is an Eligible Designated Beneficary. See the DAE form for specific details. • Annuitization: Once elected, is irrevocable. Payments outside of the frequency selected on the Deferred Annuitization Election (DAE) Form are not permitted. Please select your option on the DAE form. Restrictions may apply. AAF-0107AO.26 Page 10 of 12 (11/2024) Option 5: Life Expectancy Distribution Option • Life -expectancy scheduled withdrawals: Distributions made under this option are based on the beneficial owner's life expectancy. The amount is calculated each year. Distributions must be taken at least annually. For Qualified Contracts • Availability when the decedent passed on or before December 31, 2019: There are no limits on payments to the Beneficiary. • Availability when the decedent passed on or after January 1, 2020: Payments to a Beneficiary are limited on Qualified contracts unless the beneficiary is an Eligible Designated Beneficiary (EDB). • Eligible Designated Beneficiary (EDB): If the beneficiary of a Qualified contract is a Spouse, Chronically III or Chronically Disabled (to verify we'll require our Chronically 111 or Disabled Individual Physician Certification Form, please contact us at 800-848-6331 for more details) or an adult that is older than or no more than 10 years younger than the decedent, they are considered an EDB and can receive payments for the full term elected. • Minor Child of the Decedent: A minor child is considered an EDB. However, Nationwide will not pay insurance proceeds to minors. A court appointed guardian of the estate, conservator, custodian under a state's Uniform Transfer to Minors Act or a trust typically receive these funds on behalf of a minor. Contact your attorney to discuss the timely availability of monies intended for the minor's benefit. • Payments: Nationwide will issue payments to the Appointee until the minor reaches age 18. Any remaining payments at that time will continue to the beneficiary directly for up to 10 years. We'll issue any contract proceeds remaining at the end of that 10 year period as a lump sum payment. • Non -Eligible Beneficiary: Cannot elect a Life Expectancy Distribution Option. • Election: This option must be selected, and distributions must begin, by December 31 of the year after the date of death. (example: If date of death is 6/1/2025, delay distributions must begin by 12/31/2026). • Qualified Plans only: Beneficial owner contracts will be set up as Beneficially Owned Nationwide IRAs, unless we receive direction otherwise. • IRAs only: As long as decedent is the same, you may combine monies from this annuity contract with another beneficially -owned Nationwide IRA as a transfer. • RMD in the year of the owner's death: If the decedent owner has reached their Required Beginning Date (RBD), the beneficial owner must withdraw an amount greater than or equal to the decedent owner's RMD amount. • Calculation: After the first year, the beneficial owner must take at least annually an amount greater than or equal to the RMD amount calculated based on their own life expectancy. For Non -Qualified Contracts • Election: This option must be selected, and distributions must begin within a year after the date of death (example: If date of death is 6/1/2025, elections must be made and distributions must begin by 6/1/2026). If the election isn't made and/or distributions don't begin within a year after the date of death, then this option is no longer available and we'll default to the 5-Year Distribution Option. Option 6: Lump Sum Payment • This option is a single check or direct deposit payable to the beneficiary. • Distributions will be mailed directly to the address you give us under the Beneficiary Information Section, unless you fill out an alternate address, or if you provide us with instruction for EFT payments to your bank account. This is to help minimize the risk of a 50% penalty for Qualified Money Contracts (401, 403(b), Governmental 457(b), and all IRA types) when distributions are not withdrawn in a timely manner. • Any tax withholding instructions should be indicated in the Tax Withholding Election section of this form. If no tax withholding instructions are provided, we will automatically withhold 10% federal income taxes as well as any applicable mandatory state taxes. • Any amount distributed from the annuity, if taxable, will be reported to the IRS and to you on form 1099-R by Nationwide Life Insurance Company or Nationwide Life and Annuity Insurance Company for the calendar year in which the money is distributed. • Where the owner and annuitant are not the same person, and the owner dies, the contract value instead of the death benefit is payable. The new owner must distribute the funds within 5 years, elect the life expectancy option, or take a lump sum. Because this is not a death benefit claim, any withdrawals may be subject to CDSC. AAF-0107AO.26 Page 11 of 12 (11/2024) Section 4: Payment Method Direct Deposit • Date of Deposit: The deposit(s) to your checking or savings account will normally occur up to four (4) business days after the date of the withdrawal from the annuity contract. • Account Verification: In processing your one-time or recurring credit transaction, Nationwide uses consumer information to verify ownership of the receiving bank account to reduce the possibility of fraud. If there is an inconsistency in the information you have provided to us and the authorized bank account holder's information, or if you fail to provide adequate account information, a paper check will be mailed to the address of record. • For Commercial Bank Account Owners Only: Each of Nationwide and the Commercial Bank Account Owner identified on this form agree to be bound by Nacha Operating Rules and acknowledges that the origination of ACH transactions to this account must comply with applicable U.S. Law. • Corporate Account Ownership: Where the owner of the account is a corporation, please provide a corporate resolution or a letter from the company or bank confirming the individual who is authorized to sign checks on behalf of the company. This authorized person must sign this form as the bank account owner. • Trust Ownership: Where the owner of the account is a trust, please provide a Certification of Trust (Trust Certificate) that provides necessary information to validate the trust including but not limited to the legal Trust name and effective date, the Trustee(s) authorized to act on behalf of the Trust (generally and with respect to the trust account indicated on this form) including any successor Trustee(s), and the Trust's tax identification number. • Owner Authorization: By signing this form, you authorize Nationwide Life Insurance Company and/or Nationwide Life and Annuity Insurance Company to electronically credit (deposit) and/or correct by electronic debit (withdrawal) any refund or payment due to you to the bank account listed on this form as allowed by U.S. law. You also authorize your bank to credit or debit your account accordingly. • Joint Account Owners: If this bank account is a joint account, authorization by one bank account owner constitutes authorization by all bank account owners - whether a current owner of this account or added after this authorization is signed. • Stopping Electronic Deposits: Your authorization allows us to make one or more deposits (and/or corrections by electronic debit) to this account, unless you tell us you want to stop. To withdraw your authorization, you must notify us by calling 800-848-6331. Please provide notification to us at least 10 days in advance of when our authorization should end. Doing so allows us and your bank to take action. NOTE: If you withdraw your authorization, Nationwide will cease making payments to your bank account. Your benefit payments will continue, but instead of direct deposit, a check will be mailed to your address of record. Digital Payment • Account Verification: In processing your request to electronically transfer funds, Nationwide may use consumer information to verify ownership of the receiving bank account to reduce the possibility of fraud. If there is an inconsistency in the information you have provided to us and the authorized bank account holder's information, a paper check will be mailed to the address of record. Transfer to Another Carrier or open a New Nationwide Annuity • New Account: The new account must be a Beneficially Owned or Inherited account if the beneficiary is a non -spouse. Section 5: Tax Withholdings • Tax liability: You are liable for all federal and state income tax withholdings on the taxable portion of the withdrawal. You may also be subject to federal tax penalties under the estimated tax payment rules if your estimated tax withholding payments are not enough. • Tax reporting: Any taxable amount distributed from the contract will be reported as ordinary income to the IRS and you on Form 1099-R by Nationwide Life Insurance Company or Nationwide Life and Annuity Company for the calendar year in which the funds are distributed. • Withholdings on 403(b)/Qualified Plans: There is a mandatory 20% withholding if the distribution is an eligible rollover distribution (ERD), unless the ERD is paid directly to an eligible retirement plan in a direct rollover. For RMDs, the mandatory withholding applies on any distribution amount in EXCESS of your RMD, if the excess qualifies as an ERD. If the distribution is not an ERD, the withholding is optional and the default tax withholding will be 10% if no election is received. Once withholding has been taken on a distribution, it cannot be reversed: however, future distributions can be changed. • State withholding: Nationwide will round up to the next whole dollar as required by state regulations. If the amount of state tax you request is less than the state requires, we'll attempt to accommodate the request in accordance with required state specific regulations. Nationwide, the Nationwide N and Eagle is a service marks of Nationwide Mutual Insurance company_ :f 2024 Nationwide AAF-0107AO.26 Page 12 of 12 (11/2024) Form W-4R Depertment of the Treasvri hternal Revenue Service Withholding Certificate for Nonperiodic Payments and Eligible Rollover Distributions 1a First name and middle initial Citv or to»ri, state, and ZIP code Give Form W-4R to the payer of your retirement payments. OMB No. 1545-0074 20025 1b Social security number Your withholding rate is determined by the type of payment you will receive. • For nonperiodic payments. the default withholding rate is 10%. You can choose to have a different rate by entering a rate between 0% and 100% on line 2. Generally, you can't choose less than 10% for payments to be delivered outside the United States and its territories. • For an eligible rollover distribution, the default withholding rate is 20%. You can choose a rate greater than 20% by entering the rate on line 2. You may not choose a rate less than 20%. See page 2 for more information. 2 Complete this line if you would like a rate of withholding that is different from the default withholding rate. See the instructions on page 2 and the Marginal Rate Tables below for additional information. Enter the rate as a whole number (no decimals) . . . . . . . . . . . . . . . . 2 Sign Here Your signature ;This form is not valid unless you sign it.,i General Instructions Section references are to the Internal Revenue Code Future developments. For the latest information about any future developments related to Form W-4R, such as legislation enacted after it was published. go to www.irs.gov/FormW4R. Purpose of form. Complete Form W-4R to have payers withhold the correct amount of federal income tax from your nonperiodic payment or eligible rollover distribution from an employer retirement plan. annuity (including a commercial annuity). or individual retirement arrangement (IRA). See page 2 for the rules and options that are available for each type of payment. Don't use Form W-413 for periodic payments (payments made in installments at regular Date intervals over a period of more than 1 year) from these plans or arrangements. Instead, use Form W-4P, Withholding Certificate for Periodic Pension or Annuity Payments. For more information on withholding, see Pub. 505. Tax Withholding and Estimated Tax. Caution: If you have too little tax withheld, you will generally owe tax when you file your tax return and may owe a penalty unless you make timely payments of estimated tax. If too much tax is withheld. you will generally be due a refund when you file your tax return. Your withholding choice (or an election not to have withholding on a nonperiodic payment) will generally apply to any future payment from the same plan or IRA. Submit a new Form W-4R if you want to change your election. 2025 Marginal Rate Tables You may use these tables to help you select the appropriate withholding rate for this payment or distribution. Add your income from all sources and use the column that matches your filing status to find the corresponding rate of withholding. See page 2 for more information on how to use this table. Single or Married filing separately Married filing jointly or Qualifying surviving spouse Head of household Totai income Tax rate for every Totai income Tax rate for every Totai income Tax rate for every over— dollar more over— dollar more over— dollar more $0 0% $0 0% $0 0% 15,000 10% 30,000 10% 22,500 10% 26,925 12% 53,850 12% 39,500 12% 63,475 22% 126,950 22% 87,350 22% 118,350 24% 236,700 24% 125,850 24% 212,300 32 % 424,600 32 % 219,800 32 % 265,525 35 % 531,050 35 % 273,000 35 % 641, 350' 37 % 781,600 37 % 648,850 37 % If married filing separately. use $390,800 instead for this 37% rate. For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 75085T Form W-41111 120251 Fo•m WAR {2025 i Page 2 General Instructions (continued) Nonperiodic payments-10% withholding. Your payer must withhold at a default 10% rate from the taxable amount of nonpenodic payments unless you enter a different rate on line 2. Distributions from an IRA that are payable on demand are treated as nonperiodic payments. Note that the default rate of withholding may not be appropriate for your tax situation. You may choose to have no federal income tax withheld by entering "-0-" on line 2. See the specific instructions below for more information. Generally, you are not permitted to elect to have federal income tax withheld at a rate of less than 10% (including "-0-") on any payments to be delivered outside the United States and its territories. Note: If you don't give Form W-4R to your payer, you don't provide an SSN, or the IRS notifies the payer that you gave an incorrect SSN, then the payer must withhold 10% of the payment for federal income tax and can't honor requests to have a lower (or no) amount withheld. Generally, for payments that began before 2025, your current withholding election (or your default rate) remains in effect unless you submit a Form W-4R. Eligible rollover distributions-20% withholding. Distributions you receive from qualified retirement plans (for example, 401(k) plans and section 457(b) plans maintained by a governmental employer) or tax-sheltered annuities that are eligible to be rolled over to an IRA or qualified plan are subject to a 20% default rate of withholding on the taxable amount of the distribution. You can't choose withholding at a rate of less than 20% (including "-0-"). Note that the default rate of withholding may be too low for your tax situation. You may choose to enter a rate higher than 20% on line 2. Don't give Form W-4R to your payer unless you want more than 20% withheld. Note that the following payments are not eligible rollover distributions for purposes of these withholding rules: • Qualifying "hardship" distributions: • Distributions required by federal law, such as required minimum distributions: • Distributions from a pension -linked emergency savings account: • Eligible distributions to a domestic abuse victim: • Qualified disaster recovery distributions: • Qualified birth or adoption distributions: and • Emergency personal expense distributions_ See Pub. 505 for details. See also Nonperiodic payments- 10% withholding above. Payments to nonresident aliens and foreign estates. Do not use Form W-4R. See Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities, and Pub. 519. U.S. Tax Guide for Aliens, for more information. Tax relief for victims of terrorist attacks. If your disability payments for injuries incurred as a direct result of a terrorist attack are not taxable. enter "-02' on line 2. See Pub. 3920, Tax Relief for Victims of Terrorist Attacks, for more details. Specific Instructions Line 1 b For an estate, enter the estate's employer identification number (EIN) in the area reserved for "Social security number." Line 2 More withholding. If you want more than the default rate withheld from your payment, you may enter a higher rate on line 2. Less withholding (nonperiodic payments only). If permitted, you may enter a lower rate on line 2 (including "-0-") if you want less than the 10% default rate withheld from your payment. If you have already paid, or plan to pay, your tax on this payment through other withholding or estimated tax payments, you may want to enter "-0-". Suggestion for determining withholding. Consider using the Marginal Rate Tables on page 1 to help you select the appropriate withholding rate for this payment or distribution. The tables are most accurate if the appropriate amount of tax on all other sources of income, deductions, and credits has been paid through other withholding or estimated tax payments. If the appropriate amount of tax on those sources of income has not been paid through other withholding or estimated tax payments, you can pay that tax through withholding on this payment by entering a rate that is greater than the rate in the Marginal Rate Tables. The marginal tax rate is the rate of tax on each additional dollar of income you receive above a particular amount of income. You can use the table for your filing status as a guide to find a rate of withholding for amounts above the total income level in the table. To determine the appropriate rate of withholding from the table, do the following. Step 1: Find the rate that corresponds with your total income not including the payment. Step 2: Add your total income and the taxable amount of the payment and find the corresponding rate. If these two rates are the same. enter that rate on line 2. (See Example 1 below.) If the two rates differ, multiply (a) the amount in the lower rate bracket by the rate for that bracket, and (b) the amount in the higher rate bracket by the rate for that bracket. Add these two numbers: this is the expected tax for this payment. To get the rate to have withheld, divide this amount by the taxable amount of the payment. Round up to the next whole number and enter that rate on line 2. (See Example 2 below.) If you prefer a simpler approach (but one that may lead to overwithholding), find the rate that corresponds to your total income including the payment and enter that rate on line 2. Examples. Assume the following facts for Examples 1 and 2. Your filing status is single. You expect the taxable amount of your payment to be $20,000. Appropriate amounts have been withheld for all other sources of income and any deductions or credits. Example 1. You expect your total income to be $65,000 without the payment. Step 1: Because your total income without the payment, $65.000, is greater than S63,475 but less than S118,350, the corresponding rate is 22%. Step 2: Because your total income with the payment, $85.000, is greater than $63.475 but less than $118.350, the corresponding rate is 22%. Because these two rates are the same. enter "22" on line 2. Example 2. You expect your total income to be $61,000 without the payment. Step 1: Because your total income without the payment, $61,000, is greater than S26,925 but less than S63,475, the corresponding rate is 12%. Step 2: Because your total income with the payment, $81.000, is Form W-4R (2025) Page 3 greater than $63.475 but less than $118.350, the corresponding rate is 22%. The two rates differ. S2.475 of the $20.000 payment is in the lower bracket 1;$63,475 less your total income of $61,000 without the payment), and $17.525 is in the higher bracket ($20,000 less the $2,475 that is in the lower bracket). Multiply $2,475 by 12% to get $297. Multiply $17,525 by 22% to get $3,856. The sum of these two amounts is $4,153. This is the estimated tax on your payment. This amount corresponds to 21 % of the S20,000 payment (S4.153 divided by $20.000). Enter "21" on line 2. Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required to provide this information only if you want to (a) request additional federal income tax withholding from your nonperiodic payment(s) or eligible rollover distribution(s); (b) choose not to have federal income tax withheld from your nonperiodic payment(s), when permitted; or (c) change a previous Form W-4R (or a previous Form W-41P that you completed with respect to your nonperiodic payments or eligible rollover distributions). To do any of the aforementioned, you are required by sections 3405(e) and 6109 and their regulations to provide the information requested on this form. Failure to provide this information may result in inaccurate withholding on your payment(s). Failure to provide a properly completed form will result in your payment(s) being subject to the default rate: providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia. and U.S. commonwealths and territories for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103. The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler. we would be happy to hear from you. See the instructions for your income tax return. CITY OF FAYETTEVILLE ® ARKANSAS J TO: Mayor Rawn THRU: Keith Macedo, Interim Chief of Staff Yolanda Fields, Community Resources Director Hannah Hungate, Assistant City Attorney FROM: Steve Dotson, Chief Financial Officer DATE: April 11, 2025 SUBJECT: Life Insurance Claim Form STAFF MEMO The City was notified that the Fayetteville Animal Shelter is named as a beneficiary on the life insurance policy of Susan J. Shelton. Nationwide Life Insurance Company has sent an annuity beneficiary claim form. The form provides several options on regarding payment to the City. I am recommending that the City elect a one time lump sum withdrawal of the full value of the benefit. Mailing Address: 113 W. Mountain Street www.fayetteville-ar.gov Fayetteville, AR 72701