Stable Value Account Group Annuity Withdrawal Form - Gemba Supplemental Retirement
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1
2Stable Value Account
Group Annuity Withdrawal Form
GEMBA Supplemental Retirement
Pl
Solutions today for a secure financial tomorrow
Please return this form to GEBA:
Tel: (301) 688-7912 or (800) 826-1126
Mail: P.O. Box 206, Annapolis Junction, MD 20701-0206
Monday-Friday: 8:00AM – 4:30PM
Fax: (301) 688-694 or Email:
Member Information:
Name:
Social Security No:
Member ID: (leave blank if unknown)
Address:
City:
State:
Zip Code:
Email Address:
Home Phone:
Black/Non-Classified Phone No.:
Reason for Withdrawal:
Date of Withdrawal:
(see annual withdrawal schedule for due
dates)
Retirement
Next withdrawal date
Disability
On specified withdrawal date: ________________
Death
Quarterly on first date of the quarter
Required Minimum Distribution
Quarterly on last date of the quarter
Other: _____________________________________
Annually (Select Month): _____________________
Withdrawal Instructions:
Total Distribution – Withdrawal of my Entire Annuity Account Balance
Partial Distribution: $ ___________________________
Check is to be made payable to:
Participant
Trustee
Beneficiary(ies)
Other: _______________________
Mail To:
Name: ___________________________________________________ SSN: __________________ Percent: ______________
Address: _________________________________________________ City: _________________ State: ______ Zip: __________
If being sent directly to a bank on your behalf, please provide account number: __________________________________________
Total 1035 Exchange
I designate the following as recipient for the portion of my eligible 1035 Exchange that I elected to directly transfer:
Name of Financial Institutions*: _____________________________________
Account No.: __________________________
Address: _________________________________________________ City: _________________ State: ______ Zip: __________
*In addition to this form, participants transferring funds to another financial institution must submit completed 1035 exchange paperwork from the new
institution.
Updated 5/16
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