Form # 322 - Cash Balance Account (Cba) Distribution Request
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1Form # 322
Revised 9/2015
1400 West Third, Little Rock, AR 72201
Phone (501) 682-1517 or (800) 666-2877
Fax (501) 682-2359
Website -
Cash Balance Account (CBA) Distribution Request
Member Information
Member's Name______________________________________________ SSN________________________________
Mailing Address___________________________________________________________________________________
City _______________________________ State ______________________________
Zip ____________________
Telephone Number (____) ______________________ E-mail Address ______________________________________
I elect the following distribution from my Cash Balance Account:
$__________ Gross Distribution (20% Federal and 5% State taxes (Arkansas residents only)
will be withheld from this amount)
$__________ To be rolled over to an eligible account at my chosen financial institution
(Agreement of Depository Trustee must be completed). This cannot be a
checking or savings account.
Minimum rollover amount is $200.
$___________Total distribution. (Amount paid directly to me + amount rolled over)
Minimum total distribution amount is $200
By my signature, I authorize ATRS to make distributions from my Cash Balance Account as directed above. I
understand that ATRS is required to withhold 20% Federal and 5% State income taxes from amounts not rolled
over. I have reviewed the distribution options above and understand that once submitted the distribution request is
irrevocable.
Member's Signature ______________________________________________ Date ________________________
Failure to complete this application correctly will result in delay of payment.
Agreement of Depository Trustee
In accordance with the authorization of the depositor named herein, I _________________________ (print name), as
trustee of an eligible retirement plan under IRS Code §402(c), agree to deposit the forthcoming rollover amount from
Arkansas Teacher Retirement System into the following account:
Name of Depository Institution_________________________________________________________________________
Contact Name (Please Print) __________________________________________________________________________
Mailing Address_____________________________________________________________________________________
City _________________________________________ State _____________________
Zip ________________
Account Number _______________________________
Telephone Number (____) ________________________
Type of Account
□ 401(k)
□ 401(a)
□ 403(b)/457(b)
□ Traditional IRA
□ Roth IRA
Signature of Depository Trustee Representative____________________________________ Date_________________
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Parent category: Business