Form Std Fspsrv - Separation From Employment Withdrawal Request 401(A) Plan Page 6
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1498721-01
Last Name
First Name
M.I.
Social Security Number
Number
I
Where should I send this form?
After all signatures have been obtained, this form can be sent by
OR
OR
Fax to:
Regular Mail to:
Express Mail to:
Empower Retirement
Empower Retirement
Empower Retirement
1-866-745-5766
PO Box 173764
8515 E. Orchard Road
Denver, CO 80217-3764
Greenwood Village, CO 80111
If a Loan Payoff check is included, please use an address in Section F.
Core securities, when offered, are offered through GWFS Equities, Inc. and/or other broker dealers.
GWFS Equities, Inc., Member FINRA/SIPC, is a wholly owned subsidiary of Great-West Life & Annuity Insurance Company.
Empower Retirement refers to the products and services offered in the retirement markets by Great-West Life & Annuity Insurance Company, Corporate
Headquarters: Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York, Home Office: NY, NY; and their subsidiaries and
affiliates. The trademarks, logos, service marks, and design elements used are owned by their respective owners and are used by permission.
NO_GRPG 56767/
GU22
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STD FSPSRV
07/31/17
98721-01
WITHDRAWAL
DOC ID: 492627235
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Page 6 of 14
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