Choate v. Wilmington Trust

Case No. 17-250-RGA

U.S. District Court for the District of Delaware

If you received a personalized notice in the mail or via email with a Notice ID and Confirmation Code, please enter the codes you were provided below.

Please remember to enter the full Notice ID exactly as it appears on your personalized Notice, (i.e. MRM1234).

SETTLEMENT PAYMENT DISTRIBUTION ELECTION FORM FOR FORMER ESOP PARTICIPANTS

PLEASE COMPLETE THIS FORM ONLY AFTER YOU HAVE READ AND UNDERSTOOD THE ACCOMPANYING CLASS NOTICE AND SPECIAL TAX NOTICE. IF YOU DO NOT RETURN THE FORM, YOU WILL RECEIVE YOUR PORTION OF THE SETTLEMENT, AFTER APPLICABLE TAXES ARE WITHHELD, BY CHECK.


* Required Fields
STEP I: ROLLOVER OR DIRECT PAYMENT

Please complete the following tax information if you would like additional tax withheld.

Federal Tax Withholding: 20% Mandatory

State Tax Withholding: Variable %
(Mandatory withholding may also apply depending on your State)

STEP II: SIGNATURE AND DATE

By signing below and returning the form, I consent to distribution of the settlement payment and affirmatively waive the unexpired portion of the minimum 30-day notice period during which I am entitled to consider this election.

Your Election Form has been submitted successfully.

Please print this page for your records.

Your Election Details

Submitted Election ID:
Confirmation Code:
You will need the above Submitted Election ID and Confirmation Code if you would like to edit your Election at a later time, so please print this page for your records.
CLAIM INFORMATION
Name
Street Address
Street Address 2
City
State
Zip Code
Email
Phone
Signature
Date

If you have any questions regarding your Election, please provide the Submitted Election ID listed above and email us at info@MRMCESOPSettlement.com