Form Std Fspsrv - Separation From Employment Withdrawal Request 401(A) Plan

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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.
For questions regarding this form, refer to the attached Participant Withdrawal Guide ("Guide"), visit the website at or contact Service
Provider at 1-800-352-0313.
Return Instructions for this form are in Section I.
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)
(
)
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
/
TNER
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STD FSPSRV
07/31/17
98721-01
WITHDRAWAL
DOC ID: 492627235
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