Submit Claim | Columbia University 403(b) Settlement

FORMER PARTICIPANT CLAIM FORM

Please click the link for GENERAL INSTRUCTIONS

This Former Participant Claim Form is ONLY for Class Members who are Former Participants, or the beneficiaries, alternate payees or attorneys-in-fact of Former Participants (all of whom will be treated as Former Participants). A Former Participant is a Class Member who did not have a plan account with a balance greater than $0 as of March 31, 2021.

This form must be completed, signed and filed electronically through this claims portal by September 28, 2021 or mailed with a postmark date no later than September 28, 2021 to the Settlement Administrator in order for you to receive your share of the Settlement proceeds. Former Participants who do not complete and timely return this form will not receive any Settlement payment. Please review the instructions below carefully. If you have questions regarding this Claim Form, you may contact the Settlement Administrator as indicated below.

PART 1: INSTRUCTIONS FOR COMPLETING FORMER PARTICIPANT CLAIM FORM

Complete this claim form and print a copy of the completed Former Participant Claim Form, for your records.
If you wish to file your completed Former Participant Claim Form by mail, it must postmarked no later than September 28, 2021 to the Settlement Administrator at the following address:
The Columbia University 403(b) Settlement Administrator
1650 Arch St. Suite 2210
Philadelphia, PA 19103
If you prefer to file your claim electronically, you may use this claims portal.
It is your responsibility to ensure the Settlement Administrator has timely received your Former Participant Claim Form.
Other Reminders:
- You must provide date of birth, signature and a completed Substitute IRS Form W-9, which is Part 5 of this form.
- If you desire to do a rollover and you do not complete in full the rollover information in Part 4 Payment Election of the Settlement Distribution Form, payment will be made to the Former Participant.
- If you change your address after sending in your Former Participant Claim Form, please send your new address to the Settlement Administrator.
- Timing Of Payments To Eligible Settlement Class Members. Please note that Settlement payments are subject to the Settlement Agreement’s receiving final Court approval. If the Settlement Agreement is approved and if you are entitled to a Settlement payment under the terms of the Settlement, such payments will be distributed no earlier than late 2021 due to the need to process and verify information for all Settlement Class Members who are entitled to a payment and to compute the amount of each payment. Payments may be further delayed if any appeals are filed.
Questions? If you have any questions about this Former Participant Claim Form, please call the Settlement Administrator at (844)-292-2217. The Settlement Administrator will provide advice only regarding completing this form and will not provide financial, tax or other advice concerning the Settlement. You therefore may want to consult with your financial or tax advisor. Information about the status of the approval of the Settlement, Settlement administration, and claim processing is available on this website.

You may be eligible to receive a payment from a class action settlement. The Court has preliminarily approved the class settlement of Cates, et. al. v. Trustees of Columbia University in the City of New York, Case No. 16-6524 (S.D.N.Y.). That settlement provides allocation of monies to the individual accounts of Settlement Class Members who had plan accounts with a positive balance in the Retirement Plan for Officers of Columbia University and the Columbia University Voluntary Retirement Savings Plan (collectively the “Plans”) as of March 31, 2021 (“Current Participants”). Settlement Class Members who are entitled to a distribution but who did not have a plan account with a positive balance as of March 31, 2021 (“Former Participants”) will receive their allocation in the form of a check or rollover if and only if they mail a valid Former Participant Claim Form postmarked no later than September 28, 2021 to the Settlement Administrator. For more information about the Settlement, please call (844)-292-2217 or e-mail to Info@columbia403bplansettlement.com.

Because you are a Former Participant (or beneficiary of a Former Participant) in the Plans, you must decide whether you want your payment (1) sent payable to you directly or (2) to be rolled over into another eligible retirement plan or into an individual retirement account (“IRA”). To make that choice, please complete and mail this Former Participant Claim Form that is postmarked no later than September 28, 2021 to the Settlement Administrator. If you do not indicate a payment election, your payment will be sent payable to you directly.

PART 2: PARTICIPANT INFORMATION

First Name *

Middle

Last Name *

Country *

Mailing Address *

City *

State *

Zip Code *

Home Phone

Work Phone or Cell Phone

👁 Participant’s Social Security Number *

Participant’s Date of Birth *

Email Address *

Check here if you were a Former Participant but did not receive this Claim Form in the mail. This may be because you were a participant in the Plans only for a brief period.

* Required Fields

PART 3: BENEFICIARY OR ALTERNATE PAYEE INFORMATION (IF APPLICABLE)

Check here if you are the surviving spouse or other beneficiary for the Former Participant and the Former Participant is deceased. Documentation must be provided showing current authority of the representative to file on behalf of the deceased. Please complete the information below and then continue on to Parts 4 and 5 on the next page.

Check here if you are an alternate payee under a qualified domestic relations order (QDRO), or attorney-in-fact for the Former Participant. The Settlement Administrator may contact you with further instructions. Please complete the information below and then continue on to Parts 4 and 5 on the next page.

Your First Name

Middle

Last Name

👁 Your Social Security Number *

Your Date of Birth *

Your Mailing Address

City

State

Zip Code

PART 4: PAYMENT ELECTION

Payment to Self – A check subject to mandatory federal and applicable state withholding tax will be mailed to your address on the previous page.

Direct Rollover to an Eligible Plan – Check only one box below and complete Rollover Information Section Below:

Government 457(b)

401(a)/401(k)

403(b)

Direct Rollover to a Traditional IRA

Direct Rollover to a Roth IRA (subject to ordinary income tax)

Rollover Information:

Company or Trustee’s Name (to whom the check should be made payable)

Company or Trustee’s Mailing Address 1

Company or Trustee’s Mailing Address 2

Company or Trustee’s City

State

Zip Code

Account Number

Company or Trustee’s Phone Number

PART 5: SIGNATURE, CONSENT, AND SUBSTITUTE IRS FORM W-9

UNDER PENALTIES OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA, I CERTIFY THAT ALL OF THE INFORMATION PROVIDED ON THIS FORMER PARTICIPANT CLAIM FORM IS TRUE, CORRECT AND COMPLETE AND THAT I SIGNED THIS FORMER PARTICIPANT CLAIM FORM.

The Social Security number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

I am a U.S. Person (including a U.S. resident alien)

Signature *

Date

Cates, et. al. v. Trustees of Columbia University in the City of New York

Case No. 16-6524

United States District Court for the Southern District of New York

FORMER PARTICIPANT CLAIM FORM

Please click the link for GENERAL INSTRUCTIONS

Your Claim Form has been submitted successfully.

Submitted Claim ID:
Confirmation Code:
You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
CLAIM INFORMATION
First Name
Middle
Last Name
Mailing Address
City
State
Province
Zip Code
Postal Code
Country
Home Phone
Work Phone or Cell Phone
Email Address