Form Std Fspsrv - Separation From Employment Withdrawal Request 401(A) Plan (Page 4 of 14) in pdf

98721-01

Last Name

First Name

M.I.

Social Security Number

Number

How will my income taxes be withheld?

(Continue to the next section after completing.)

Not applicable if requesting a Rollover, unless I need to satisfy my required minimum

distribution.

I should refer to and read the attached 402(f) Notice of Special Tax Rules on Distributions and the Guide, as well as information from the

Department of Revenue for my state of residence.

If applicable, I must attach IRS Form W-4P and/or my State Income Tax withholding form to make tax elections when required. In the event

these forms are required for my withdrawal and not submitted, or in the event my withholding election(s) below are left blank or do not comply

with the applicable Federal and State regulations, Service Provider will withhold taxes from this withdrawal in accordance with applicable Federal

and State regulations.

Federal Income Tax

State Income Tax

Federal Income Tax will be withheld based on the reason and type

State Income Tax withholding is mandatory in some states and will

●

of withdrawal I have selected.

be withheld regardless of any election below. I would like additional

State Income Tax withholding:

I would like additional Federal Income Tax withholding

(Optional)

_________________% or $_________________

(This is in addition to any mandatory State Income Tax withheld based on the

(This is in addition to any mandatory Federal Income Tax withheld based on

reason and type of withdrawal.)

the reason and type of withdrawal I have selected.)

Certain states allow an election for no State Income Tax withholding

●

Required Minimum Distribution Only

(Age 70½ or Older)

depending on the reason and type of withdrawal I have selected.

10% of my taxable distribution will be withheld for Federal Income

●

For these states only, State Income Tax will be withheld unless I

Tax, unless I check the box below:

elect otherwise below.

Do not withhold 10% Federal Income Tax from my Required

If the checkbox is not marked below, I choose to have State

Minimum Distribution.

Income Tax withheld from my withdrawal. I would also like to have

I would like additional Federal Income Tax withholding

additional State Income Tax withholding:

(Optional)

_________________% or $_________________

(This is in addition to any 10% Federal Income Tax withholding)

(This is in addition to any elective State Income Tax withheld based on the

reason and type of withdrawal.)

Do not withhold State Income Tax

(if election is permitted and I have

attached the proper election form if required by my state).

Certain states do not require mandatory State Income Tax

●

withholding but allow to elect State Income Tax withholding

depending on the reason and type of withdrawal I have selected.

I would like State Income Tax withheld - Optional State Income

Tax withholding:

_________________% or $_________________

(If this optional income tax election is permitted. I also have attached the

proper income tax election form if required by my state to elect this optional

withholding).

Signatures and Consent

(Signatures must be on the lines provided.)

(After receiving ALL required signatures, continue to the next section.)

My Consent

(Please sign on the ‘My Signature’ line below.)

I acknowledge that I have read, understand and agree to all pages of this Separation from Employment Withdrawal Request, the Participant

Withdrawal Guide and the 402(f) Notice of Special Tax Rules on Distributions and affirm that all information that I have provided is true and correct.

I understand the following:

Any election for a 100% withdrawal reflected on this Withdrawal Request form is effective for 180 days and also applies to any additional

●

contributions or other residual amounts made or credited to my account for 180 days, subsequent to this 100% Withdrawal Request. I

acknowledge and consent to the Plan’s subsequent distribution of any such residual amounts in accordance with this election.

It is my responsibility to ensure that this election conforms with all applicable provisions of the Internal Revenue Code (the "Code") and, if

●

applicable, that the Plan into which I am rolling money over will accept the dollars.

I am liable for any income tax and/or penalties assessed by the IRS and/or state tax authorities for any election I have chosen.

●

Once a payment has been processed, it cannot be changed or reversed.

●

In the event that any section of this form is incomplete or inaccurate, Service Provider may not process the transaction requested on this form

●

and may require a new form or that I provide additional or proper information before the transaction can be processed.

Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund’s

●

prospectus or other disclosure documents. I will refer to the fund’s prospectus and/or disclosure documents for more information.

Under penalty of perjury, I certify that the Social Security Number (or Taxpayer Identification Number) shown in Section A is correct. I am a

●

U.S. person if I marked U.S. citizen or U.S. resident alien box in Section A of this form.

Service Provider is required to comply with the regulations and requirements of the Office of Foreign Assets Control, Department of the

●

Treasury ("OFAC"). As a result, Service Provider cannot conduct business with persons in a blocked country or any person designated by OFAC

as a specially designated national or blocked person. For more information, please access the OFAC website at:

about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx.

For at least 30 days after my receipt of the 402(f) Notice of Special Tax Rules on Distributions, I have the right to consider whether to consent

●

to a withdrawal of the vested account balance or elect a direct rollover of any vested portion of the eligible rollover withdrawal. By signing this

form less than 30 days after I received the 402(f) Notice of Special Tax Rules on Distributions, I affirmatively waive any unexpired portion of the

30 day period and affirmatively elect a withdrawal from the account pursuant to this Separation from Employment Withdrawal Request form.

Additional authentication may be necessary before my withdrawal is processed and/or payment released.

●

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STD FSPSRV

07/31/17

98721-01

WITHDRAWAL

DOC ID: 492627235

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Page 4 of 14

Form Std Fspsrv - Separation From Employment Withdrawal Request 401(A) Plan Page 4

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