Distribution / Transfer / Loan Request Form
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1Distribution / Transfer / Loan Request Form
Instructions: To Facilitate processing, this form should accompany any contract exchange, rollover, distribution, or loan request paperwork
provided by your 403(b) company or representative. This form must be completed by the employee and/or agent.
IMPORTANT!
Please check this box if you are returning additional information for a previously submitted transaction.
Employer
Termination Date (If Applicable)
Employee Name
Employee Mailing Address
SSN
DOB
City, State, Zip
Employee Phone
Employee Email
Please check all your inputs for accuracy.
(Company Name)
I am requesting a
Distribution
Loan from my 403(b) or 403(b)(7) account with
Transfer from 403(b) , 403(b)(7) , 457(b) account with
IRA Rollover
In service Contract Exchange
(Company Name)
(Transaction form is invalid if date signed is more than
to
.
90 days from date of attached forms.)
(Company Name)
Employee Signature
Date Signed
Once completed, GLP Strategic Administrative Group should forward this form and all paperwork associated with this transaction to:
Employee (to same address as above)
Representatives Name
Send to the following fax
Fax
or mailing address:
Address
Address
Representatives e-mail
Company - Send to the following fax or mailing address:
Fax
Address
Address
Submit Completed Form and All Accompanying Paperwork To:
GLP Strategic Administrative Group
37000 W. 12 Mile Rd. Suite 101
Farmington Hills, Mi. 48331
Fax: 248-876-9657
DO NOT WRITE IN THIS SECTION
Transaction Request Approved:
Printed Name
Date Signed
Signature
Title
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Parent category: Business