Form Std Fspsrv - Separation From Employment Withdrawal Request 401(A) Plan (Page 7 of 14) in pdf

Participant Withdrawal Guide - 401(a) Plan

The Separation from Employment Withdrawal Request

Before completing the form, please note the following information:

I must be eligible to receive a withdrawal from my employer's Plan.

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All pages of the Separation from Employment Withdrawal Request form ("Withdrawal Form") must be returned excluding the Participant Withdrawal

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Guide and the 402(f) Notice of Special Tax Rules on Distributions.

Neither this Guide nor this Withdrawal Form are intended to provide tax or legal advice. In the preparation of this Withdrawal Form, and where I deem

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appropriate, I will seek a consultation with my accountant and/or tax advisor.

I must complete a separate Withdrawal Form for each account or plan number.

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If I am a Beneficiary, I need to complete and submit a Death Benefit Claim Request form rather than this Withdrawal Form.

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If I am an Alternate Payee, I need to complete and submit an Alternate Payee QDRO Distribution Request rather than this Withdrawal Form.

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Changes to My Request

Any changes to this Withdrawal Form must be crossed-out and initialed. If I do not initial all changes, this Withdrawal Form may be returned to me

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for verification.

Incomplete or Inaccurate Information

In the event that any section of this Withdrawal Form is incomplete or inaccurate, Service Provider may not be able to process the transaction requested

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on this Withdrawal Form. I may be required to complete a new form or provide additional or proper information before the transaction will be processed.

Section A: What is my personal information?

All information in this section must be completed.

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Personal information will be kept confidential.

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If I am a Non-Resident Alien, refer to the “How will my taxes be withheld?” section of this Guide to obtain more information about attaching an IRS

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Form W-8BEN.

Section B: What is my reason for this withdrawal?

I must designate only one withdrawal reason in order for my request to be processed. If more than one withdrawal reason is elected, this Withdrawal

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Form may be returned to me for further clarification.

Once Service Provider has processed a withdrawal, it cannot be returned.

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The following is a brief explanation of each of the withdrawal reasons and associated requirements listed on this Withdrawal Form.

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I have Separated from Employment/Retired

I would check this box to request a withdrawal from my account due to my separation from employment/retirement from the employer/company

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sponsoring this Plan.

I must indicate the date of separation from employment/retirement on the line provided.

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After-Tax Contributions and Earnings

I would check this box to request a withdrawal of my after-tax account balance, including contributions and earnings.

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Required Minimum Distribution (Age 70½)

I must be separated from employment to be able to select this option and I must enter the date that I separated from employment on the line provided.

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I would check this box if I am age 70½ or older and I want to take a one-time withdrawal of my required minimum amount. I will be responsible for

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calculating my required minimum amount every year and completing this Withdrawal Form to request payment.

If I would prefer to have my required minimum amount automatically calculated and sent to me each year, I must request an Automated Minimum

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Distribution Request form. Once the Automated Minimum Distribution Request form is completed and received by Service Provider, I will receive my

required amount without additional paperwork.

Section C: What type of withdrawal and how much am I requesting?

I must designate a type of withdrawal in order for my request to be processed.

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Once Service Provider has processed a withdrawal, it cannot be returned.

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Certain fees, charges (including contingent deferred sales charge) and/or limitations may apply.

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Unless directed otherwise by the Plan, the withdrawal will be prorated against all available investment options and all available contribution sources.

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The following is a brief explanation of each type of withdrawal listed on this Withdrawal Form.

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My Self-Directed Brokerage ("SDB") Account

If I would like to receive a withdrawal from my SDB assets, it is my responsibility to contact the SDB provider directly to liquidate the securities and

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transfer the cash to the core investments (non-SDB investments) before my withdrawal request can be processed.

Once the cash is swept into the SDB money market fund, I must request a transfer of the cash back to my Plan’s core investment options by visiting

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or by calling 1-800-352-0313.

If my Plan has a "core minimum" (the amount of investment funds, required by my Plan, that must be maintained in my core investment options at

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all times), and the transfer of funds has not been received by Service Provider prior to receipt of this Withdrawal Form, my request will be processed

from the amount that is available in the core investment options in excess of the core minimum.

For any further withdrawals, I must transfer the appropriate funds into my core investment options and submit an additional Withdrawal Form.

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Payable to Me as a One-time Withdrawal

I would check this box to have my withdrawal made payable to me and enter the requested amount.

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If I select the Net Amount box, the actual withdrawal amount will be greater than the withdrawal amount received to account for applicable income

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taxes and fees.

If I select the Gross Amount box, applicable income taxes and fees will be withheld from the gross amount, resulting in an amount less than the

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requested amount. If both or neither check box is marked, the request will be processed as a Gross Amount.

If I am electing a partial withdrawal, I must indicate the percent or amount in the lines provided.

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If I am electing this option for my Required Minimum Distribution, I must enter a dollar amount. Percentages are unavailable.

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If I am taking a withdrawal from a specific contribution source, I would enter it on the line provided. If I do not enter a contribution source, my withdrawal

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will be prorated against all of my available investment options and all available contribution sources.

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STD FSPSRV

07/31/17

98721-01

WITHDRAWAL