Form R-19125-1 - Separation From Service Distribution Request Page 2
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1
2
3Section III – Payment Information –
Please select one type of distribution below:
Lump Sum Distribution – By selecting this option you are requesting a taxable distribution.
Transfer / Rollover – Please check this box if you are requesting the amount specified in Section I to be moved to an account
with another AUL contract or another financial institution.
$ ,
,
.
Transfer / Rollover of
, with the remainder paid to me –
Please check this box if you are requesting a portion of your vested account balance to be moved to an account with another
AUL contract or another financial institution, with the remainder of the specified amount provided in Section I paid to you.
$ ,
,
.
Payment of
to me, with the remainder paid as a Transfer / Rollover –
Please check this box if you are requesting a portion of your vested account balance paid to you with the remainder moved
to an account with another AUL contract or another financial institution. Please provide gross amount above.
If applicable, please select the type of Transfer/Rollover:
Internal Transfer / Rollover – Please check this box if you are requesting your account to be moved to another
AUL contract.
AUL Account Number:
External Transfer / Rollover – Please check this box if you are requesting your account to be moved to an account
with another financial institution.
Important!
If you selected External Rollover above, please complete the rest of Section III below:
Name of Institution
Mailing Address
City
State
Zip Code
-
Account Number
Required Minimum Distributions (RMD) are not eligible to be rolled over. If AUL has processed an RMD for you in the past, then your
RMD will be distributed to you prior to a rollover distribution. The RMD will have 10% Federal tax withholding and any applicable
mandatory State tax withholding.
Account Type:
Another Qualified Plan
Traditional IRA
Roth IRA
Section IV – Participant Acknowledgement and Signature
I certify that I received the Special Tax Notice and the information provided on pages 1 and 2 is complete and accurate to the best of
my knowledge. If applicable, I certify that the qualified retirement plan or IRA named to receive my payment(s) is an eligible plan for
purposes of receiving direct rollovers. I understand that a change in my employee status may impact disability benefits under the
terms of my plan.
For 1099 reporting purposes, I certify that I am/was a Military Reservist called to active duty for at least 180 days between
September 11, 2001 and December 31, 2007 , or a member of a public safety organization separated from service on or after
age 50.
/
/
Date:
Participant Signature
M M
D
D
Y
Y
Y
Y
R-19125-2
3/28/08
Page 2 of 3
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