Form R-19125-1 - Separation From Service Distribution Request
Download a blank fillable Form R-19125-1 - Separation From Service Distribution Request in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form R-19125-1 - Separation From Service Distribution Request with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Separation from Service
Products and financial services provided by
American United Life Insurance Company
®
Distribution Request
a OneAmerica
®
company
Use this form to request: A distribution
One American Square, P .O. Box 6011
due to retirement, disability, or termination
Indianapolis, IN 46206-6011
from employment from all qualified
1-800-249-6269
retirement plans.
Please print in UPPER CASE letters in Black or Dark Blue ink!
First Name
M.I.
Last Name
Mailing Address (Please contact AUL at 1-800-249-6269 if you have a foreign address.)
City
State
Zip Code
-
Social Security Number
Daytime Telephone Number
(
)
-
-
-
Plan Number
Plan Name / Employer
Email Address
Section I – Distribution Amount
A. Full Withdrawal
Check this box to request your entire vested account balance less any applicable tax withholding and/or fees. Certain
money types may be restricted based on the provisions of your plan.
B. Partial Withdrawal
Check this box for a specific cash disbursement. Specify the amount in space provided. Please provide the gross
amount (before tax withholding and any applicable fees). The amount requested will be distributed and withdrawn
proportionately from all investments and requested sources. If a dollar amount and percent are provided, the percent
will be distributed. If the requested partial withdrawal amount will leave a balance in your account less than $1,000.00,
100% of your vested account balance less any applicable tax withholding and/or fees will be distributed unless your
plan provisions restrict certain money types from being distributed.
$ ,
%
or
,
.
Section II – Tax Withholding
Federal Tax Withholding –
The Internal Revenue Service requires income tax withholding of 20% on all benefit distributions that are
not directly rolled over to another qualified retirement plan or traditional IRA. If you would like an additional amount withheld, please
indicate that additional amount below:
$ ,
.
Please withhold:
in addition to the mandatory 20%.
State Tax Withholding –
If you live in a state that requires State tax withholding if Federal tax is withheld, then we will automatically
withhold the mandatory amount for State taxes.
If State tax withholding is not required,
Please
do you want State tax withheld from
%
No
Yes
withhold:
your payment?
R-19125-1
3/28/08
Page 1 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business