Separation from Employment Withdrawal Request
Governmental 457(b) Plan
County of Los Angeles Pension Savings Plan
98996-05
When would I use this form?
When I am requesting a withdrawal and I am no longer employed by the employer/company sponsoring this Plan.
When I am requesting a withdrawal and I am no longer employed by the County of Los Angeles.
Additional Information
For purposes of this form, the terminology 'Separation' is the same as 'Severance', 'Employment' is the same as 'Service' and 'Withdrawal' is the
same as 'Distribution'.
By logging into my account on the Web site at , I may confirm the address that is on file and track the status of this withdrawal
request.
For questions regarding this form, refer to the attached Participant Withdrawal Guide ("Guide"), visit the Web site at or contact
Service Provider at 1-800-947-0845.
Return Instructions for this form are in Section H.
Use black or blue ink when completing this form.
A
What is my personal information?
(Continue to the next section after completing.)
Account extension, if applicable, identifies funds
transferred to a beneficiary due to participant's
-
-
death, alternate payee due to divorce or a participant
with multiple accounts.
Social Security Number or Taxpayer Identification Number
Account Extension
(Must provide all 9 digits)
/
/
Last Name
First Name
M.I.
Date of Birth (
mm/dd/yyyy)
Married
Unmarried
Department
(
)
Daytime Phone Number
Email Address
- By providing an email address above, I am consenting to receive emails related to this request.
(
)
Select One:
Alternate Phone Number
U.S. Citizen
U.S. Resident Alien
Other/Non-Resident Alien
Country of Residence
(Required)
B
What is my reason for this withdrawal?
(Continue to the next section after completing.)
Must select only one reason.
Separation from Employment Date
: _____/_____/_____
(Required)
(mm/dd/yyyy)
I have Separated from Employment/Retired
Required Minimum Distribution
(Age 70½ or older)
Severance of employment must be verified by the County. Confirmation may take up to 60 days from severance date.
If I have over $1,000.00 in my account, in order to receive my money, I must elect to take a withdrawal by completing and returning this withdrawal
form. If I have over $1,000.00 in my account and I do not complete and return this withdrawal form, the withdrawal of my account will be delayed
until I make a request to receive benefits in the future or the later of when I reach age 70 1/2 or sever County employment. If I have $1,000.00 or
less in my account and I do not elect to take a withdrawal, my withdrawal may be delayed for 24 months following my separation from employment.
If I have been separated from employment for at least 24 months when I receive my withdrawal package and my account balance is $1,000.00 or
less, my account will be automatically distributed to me unless I complete and return this withdrawal form within 30 days.
C
What type of withdrawal and how much am I requesting?
(Continue to the next section after completing.)
100% withdrawal will be the Maximum Amount Available
I should refer to the Withdrawal Guide for a detailed description of my options. If I am under age 50 or my account balance is $5,000.00 or less,
I may only take a full withdrawal as a payment to me, direct rollover or combination of the two.
Payable to Me as a One-time Withdrawal
Amount __________% or $______________
Contribution Source:_____________________________________
Net Amount
(The amount I will receive after applicable income taxes and fees are withheld.)
Gross Amount
(The amount I will receive will be less than the amount requested after applicable income taxes and fees are withheld.)
100% Withdrawal With A Portion Payable to Me and the Remaining Balance as a Direct Rollover
Net Amount
(The amount I will receive after applicable income taxes and fees are withheld.)
Gross Amount
(The amount I will receive will be less than the amount requested after applicable income taxes and fees are withheld.)
Payable to Me Amount __________% or $______________
Direct Rollover Amount
100
% of the remaining balance
JTYL/MANUAL/(SR 1531720/1981453)
RLFL/MANUAL (SR 504264)
02/01/16
STD FSPSRV 05/07/15
98996-05
WITHDRAWAL
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