The Directed Account Plan Partial Withdrawal Request Form

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The Directed Account Plan
Partial Withdrawal
Request Form
Plan Number: 21622
PARTICIPANT NAME AND ADDRESS:
PARTICIPANT INFORMATION:
________________________________
SSN:
____________________ Date of Hire:
____________
________________________________
Daytime Phone: _____________ Date of Birth:
____________
________________________________
Employee ID:
_____________
________________________________
Payment Option:
Partial Withdrawal Cash Amount: ______________________
Partial Withdrawal Rollover Amount: ____________________ (Must Complete Partial Withdrawal Rollover Form)
EFT
(EFT information needs to be set up prior to requesting fund transfer via EFT)
Election to Waive Joint and Survivor Annuity
I have read and understand the options set forth in the Directed Account Plan Tax and Distribution Notice. I elect to waive my right to
receive p ayment of m y v ested acc ount ba lance in t he for m of a joint and surv ivor annuity. If I am not marrie d, m y signature below
constitutes a waiver of m y right to receive p ayment of m y vested account balance in the form of a life ann uity and also constit utes a
certification that I am not married.
_________________________________________ ___ ________________________ MARRIED:
Yes
No
Participant’s Signature
Date
Consent of Spouse to Waive Joint and Survivor Annuity
I, _________________________, spouse of the Participant hereby consent to the waiver of the joint and survivor annuity. I certify that I
have received a written explanation from the Plan an d I un derstand the te rms of the joint and surviv or annuity, my right not to consent
to this waiver election, the waiver election period, and the financial effect of the election not to receive benefits in the joint and survivor
annuity form. I understa nd my consent is irr evocable unless my spouse revokes the waiver election. I und erstand any change in t his
form of benefit election is subject to my consent, unless my spouse elects to receive the qualified joint survivor and annuity.
_____________________________
____________________________________________________________________________
Date
Signature of Participant’s Spouse (Must be witnessed by a Notary Public)
STATE OF: ________________________ COUNTY OF: ________________________
On this _________ day of __________________, 20____, before me appeared _____________________________ who
acknowledged herself or himself to be the person who executed the consent set forth above and acknowledged the consent to be his or
her free act and deed.
Notary Public: ________________________________
My commission expires: ________________________
SEAL:
OURCE
The amount of your withdrawal will be pro-rated across all available sources in your Plan account. If you would like the funds to
be withdrawn from a rollover source (no spousal consent required), please indicate below. By checking the rollover source box, you
validate there are enough funds available to process the withdrawal request. If there are not enough funds in the source, this request will
be rejected.
Please process this request utilizing funds from a rollover source.

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