Separation from Employment Withdrawal Request
401(a) Plan
CCOERA 401(A) Plan
98721-01
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.
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 website at , I may confirm the address that is on file and track the status of this withdrawal request.
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For questions regarding this form, refer to the attached Participant Withdrawal Guide ("Guide"), visit the website at or contact Service
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Provider at 1-800-352-0313.
Return Instructions for this form are in Section I.
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Use black or blue ink when completing this form.
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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)
(
)
Agency
Daytime Phone Number
(
)
By providing my mobile number and/or my email address below, I am consenting to receive text
Alternate Phone Number
messages and/or emails related to this request.
Mobile Phone Number -
Standard data fees and text messaging rates may apply based on my carrier.
Email Address
Select One (Required):
U.S. Citizen
U.S. Resident Alien
Non-Resident Alien or Other
Country of Residence
(Required - See Guide for IRS Form
W-8BEN information.)
B
What is my reason for this withdrawal?
(Continue to the next section after completing.)
Must select only one reason.
Separation from Employment or Retirement Date
:
/
/
(Required)
(mm/dd/yyyy)
I have Separated from Employment
Required Minimum Distribution
(Age 70½ or older)
I have Retired
After-Tax Contributions and Earnings
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
Effective Date:
(Required if requesting a future dated withdrawal within the next 180 days. If left blank and request is in good order, withdrawal
will be processed as soon as administratively feasible.)
Payable to Me as a One-time Withdrawal
Amount __________% or $______________
Contribution Source:_____________________________________
If I am electing this option for my Required Minimum Distribution, I must enter a dollar amount. Percentages are unavailable.
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
Payable to Me Amount __________% or $______________
(If the Payable to Me Amount is to fulfill my Required Minimum Distribution, I must enter
a dollar amount. Percentages are unavailable.)
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.)
NO_GRPG 56767/
GU22
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TNER
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STD FSPSRV
07/31/17
98721-01
WITHDRAWAL
DOC ID: 492627235
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