Form Std Fspsrv - Separation From Employment Withdrawal Request 401(A) Plan Page 5
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1498721-01
Last Name
First Name
M.I.
Social Security Number
Number
H
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.)
My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and
●
other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service
Provider for a withdrawal quote at 1-800-352-0313.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.
Before signing this form: My signature must be notarized by a Notary Public or witnessed by my authorized Plan Administrator if I am
requesting Direct Deposit via ACH or a Wire Transfer or if my withdrawal request will include a change of address or check delivery to
an alternate mailing address. If I use a Notary Public, the date that I sign this form must match the date of the Notary Public signature.
My Signature
Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Signature Notarization
My signature notarization only required if requesting:
Direct Deposit via ACH or Wire Transfer - May also be witnessed in the 'My Plan Administrator Witnessing' section below.
Permanent Address Change - May also be witnessed in the 'My Plan Administrator Witnessing' section below. I would like the address on my
account to be updated with this address. If I am requesting a check, I understand that it will be mailed to this
address.
Mailing Address
City/State/Zip Code
Alternate Mailing Address - May also be witnessed in the 'My Plan Administrator Witnessing' section below. I would like my withdrawal check
to be sent to the following alternate mailing address. I understand that this address will be used for this withdrawal
only and cannot be used for Periodic Installment Payments.
Alternate Mailing Address
City/State/Zip Code
For Residents of all states (except California), please have your notary complete the section below.
Notice to California Notaries using the California Affidavit and Jurat Form the following items must be completed by Notary on the state
notary form: the title of the form, the plan name, the plan number, the document date, and my name. Notary forms not containing this information
will be rejected and it will delay this request.
The date I sign this form in the ‘My Consent’ section must match the date on which my signature is notarized.
Statement of Notary
NOTE: Notary seal must be visible.
This request was subscribed and sworn (or affirmed) to before me
State of
)
on this
day of
, year
, by
SEAL
)ss.
(name of participant)
County of
)
proved to me on the basis of satisfactory evidence to be the person who
appeared before me.
Notary Public
My commission expires
/
/
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Plan Administrator Witnessing My Signature
(Please sign on the ‘Plan Administrator Signature’ line below.)
Only necessary if Notary signature is NOT obtained where indicated above.
If the participant request includes instructions for Direct Deposit via ACH or Wire Transfer or if their withdrawal request includes instructions to
make a permanent address change or for check delivery to an alternate mailing address and the participant’s signature is not notarized, I have
personal knowledge and hereby certify that this request was submitted and signed by the participant.
I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form.
Plan Administrator Signature
Date (Required)
Print Full Name
NO_GRPG 56767/
GU22
/
TNER
][
)(
][
STD FSPSRV
07/31/17
98721-01
WITHDRAWAL
DOC ID: 492627235
)(
][
)(
Page 5 of 14
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