Form 18 - Wire Instructions For A Partial Or Lump Sum Rollover Distribution (Page 2 of 2) in pdf

FORM 18 11/13

WIRE INSTRUCTIONS FOR A PARTIAL OR LUMP SUM

ROLLOVER DISTRIBUTION

ABA Retirement Funds Program (the “Program”)

Customer Contact Center: (800) 348-2272

P.O. Box 5142 • Boston, MA 02206-5142

Website:

This form must be accompanied by a Distribution Request Form, In-Service Withdrawal Form or Death Beneﬁts Claim Form.

Complete this form to have the Program wire a rollover distribution to the ﬁnancial institution directed by the participant. The employer

completes section 1. The participant completes sections 2 and 3 and mails the original form to the address shown above.

(This form should not be used for distributions that are not being rolled over. For ACH/direct deposit of non-rollover payments,

complete the Electronic Direct Deposit of Distributions Form.)

Not all banks will accept rollovers as wires. Please check with the rollover institution to conﬁrm that wires will be accepted. If the information

below is not fully completed or incorrect, a check will be sent to the participant in lieu of a wire.

EMPLOYER INFORMATION

Program Plan Number: ___ ___ ___ ___ ___ ___ Employer Tax ID Number: ___ ___ – ___ ___ ___ ___ ___ ___ ___ IRS Plan Number: ___ ___ ___

Employer’s Name: ______________________________________________ Employer’s Business Phone Number: (

)

–

In my capacity as the authorized plan representative of the retirement plan identiﬁed above, I am authorized to direct the Program on administrative

activities that facilitate recordkeeping obligations, including instructions to wire funds. Accordingly, this authorization constitutes client direction.

SIGNATURE OF AUTHORIZED PLAN REPRESENTATIVE ON BEHALF OF THE EMPLOYER (REQUIRED)

DATE

2. PARTICIPANT INFORMATION

Participant’s Name: ______________________________________________ Social Security Number: ___ ___ ___–___ ___–___ ___ ___ ___

Signature of Participant (required): _________________________________________________________________________________________

3. RECEIVING ACCOUNT INFORMATION

COMPLETE NAME(S)/REGISTRATION ON BANK ACCOUNT

(ALWAYS CONFIRM THE INFORMATION BELOW WITH YOUR ROLLOVER INSTITUTION)

Receiving Account Information:

Name of Financial Institution: ______________________________________________________________________________________________

Address of Financial Institution: (If a branch, please provide branch address.)

Street: _________________________________________________________________________________________________________________

City:______________________________________________________ State: ________________________ Zip Code: __________________

Financial Institution Phone Number (Your Local Branch*): (

)

–

*This telephone number may be used to verify wire instructions, so it is important that you provide your local branch number.

Nine-digit Financial Institution Routing Number (also known as an “ABA” number): ________________________________________________

Further Credit to Account Name: ___________________________________________________________________________________________

Further Credit to Account Number: _________________________________________________________________________________________

(THIS SECTION MAY NOT BE APPLICABLE. COMPLETE IF THIRD PARTY IS REQUIRED):

Credit the Account Name of Rollover Institution: ______________________________________________________________________________

Credit the Account Number of Rollover Institution: ____________________________________________________________________________

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Form 18 - Wire Instructions For A Partial Or Lump Sum Rollover Distribution Page 2

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