Form Std Fspsrv - Separation From Employment Withdrawal Request 401(A) Plan Page 2
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1498721-01
Last Name
First Name
M.I.
Social Security Number
Number
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
Direct Rollover Amount
100
% of the remaining balance
Eligible Retirement Plan:
401(a)
401(k)
403(b)
Governmental 457(b)
Traditional IRA
Roth IRA
(Taxable event - Subject to ordinary income taxes)
My after-tax contributions will be included in my rollover, unless I mark this box:
No, pay my after-tax contributions to me.
Rollover to an IRA or an Eligible Retirement Plan as a One-time Withdrawal
Eligible Retirement Plan:
401(a)
401(k)
403(b)
Governmental 457(b)
Amount __________% or $______________
Traditional IRA
Amount __________% or $______________
Roth IRA
Amount __________% or $______________
(Taxable event - Subject to ordinary income taxes)
My after-tax contributions will be included in my rollover, unless I mark this box:
No, pay my after-tax contributions to me.
Required Minimum Distribution
If I am requesting a 100% Withdrawal as a Direct Rollover and I am age 70½ or older by the end of this year, I am no longer working for the
employer/company sponsoring this Plan, and if I have not yet satisfied my required minimum distribution for this year, my required amount
must be distributed to me prior to processing this rollover request.
Required Minimum Distribution Amount $___________________
Also complete Required Minimum Distribution portion of the ‘How will my income taxes be withheld?’ section.
Periodic Installment Payments
(Complete the information below.)
I am requesting to establish a new Periodic Installment Payment.
I am making a change to an existing Periodic Installment Payment.
I am requesting a one-time withdrawal payable to me in the amount of $__________ or __________% and at the same time I am requesting
this Periodic Installment Payment.
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.)
First Payment Processing Date: _____/______/______
(1st - 28th only)
Frequency - Select One:
Monthly
Quarterly
Semi-Annually
Annually
Payment Type - Select One:
Amount Certain
$
(Gross Amount Only)
Period Certain
(Specific Number of Years)
Interest Only Payments, Converted to Required Minimum Distribution at age 70½
(Must have at least one
fixed investment option and attach copy of Birth Certificate or Driver’s License)
D
If I am requesting a Rollover,
To whom do I want my withdrawal payable and where should it be sent?
(Continue to the next section after completing.)
Do not complete if requesting Payable to Me.
●
If I have after-tax assets and would like to direct my after-tax contributions to a Rollover payee other than the one listed below, I must attach
a letter of instruction listing the same information that is required in this section and must include the type of payee, my name, social security
number, signature and date.
Name of Trustee/Custodian/Provider - Required (To whom the check is made payable)
Account Number
Mailing Address
City/State/Zip Code
(
)
Retirement Plan Name (if applicable)
Phone Number
E
How do I want my withdrawal delivered?
(Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order.
●
If no option is selected, all transactions will be sent by United States Postal Service ("USPS") regular mail.
●
If I would like to make a change to what I previously selected, I must cross-out and initial the change(s). If I do not initial all changes,
all transactions will be sent by USPS regular mail.
Check by USPS Regular Mail
Estimated delivery time is 7-10 business days.
●
No additional charge.
●
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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Page 2 of 14
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