Vanguard Section 403(B)(7) Plan Template
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1
2
3Vanguard Plan #
0
(Plan Name)
Vanguard Section 403(b)(7) Plan
In-Service Withdrawal Request
Please call 1-800-523-1188 with any questions regarding this form.
1. Account Information
Social Security #
Check here if address listed below is a new address.
Name
(Last, First, MI)
Address
City
State
Zip
2. Withdrawal Method
All amounts available, or
Age 59½ or Over Withdrawal -
I Elect to Withdraw:
Specific dollar amount $
taken pro-rata by fund.
Payment Instructions: (choose one)
See reverse side for additional information
Lump Sum Cash
Direct Rollover to Vanguard traditional IRA
Direct Rollover to Other
Skip to Section 3
(Complete this form and a Vanguard IRA Adoption Agreement)
Eligible Retirement Plan
(Complete this form and obtain
further instructions from receiving institution)
Installments
(Complete Installment Payment Request Form)
2a. Direct Rollover Information
You may rollover any or all of your distribution.
% To be transferred as direct rollover
%
Pre-Tax:
% To be paid to me
%
100%
Check One:
Traditional IRA
Eligible Employer Plan
(See the Special Tax Notice for the defiinition of eligible employer plan)
Trustee/Custodian
Name
(Please show name exactly as check should be made out)
Account Number
Note: If account number is not provided, the Direct Rollover check will be mailed to you.
Mail check to me
Mail check to institution at the address below.
City
State
Zip
% To be transferred as direct rollover
%
After-Tax:
% To be paid to me
%
100%
Note: After-tax assets can only be rolled over into a traditional IRA or another 403(b) plan, subject to the receiving plan's
provisions.
403(b)
Check One:
Traditional IRA
Trustee/Custodian
Name
(Please show name exactly as check should be made out)
Account Number
Note: If account number is not provided, the Direct Rollover check will be mailed to you.
Mail check to institution at the address below.
Mail check to me
City
State
Zip
(2/14/2002)
White - Vanguard
Yellow - Benefits Office
Pink - Employee
T1461_022002 ISW-93
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