Request for Distribution Form

Normal Processing
RUSH Processing (Additional $60 Fee applies except for QDRO)
REQUEST FOR DISTRIBUTION
Note: Time sensitive material. Please complete this form carefully. Missing information may delay processing. The
Request for Distribution Form Instructions and the Special Tax Notice should be reviewed prior to completing this form.
Plan/Company Name: ____________________________________________________________________________
Participant Name: _______________________________________________________________________________
Print or Type Complete Legal Name – First, MI, Last
Social Security #: _______________________ Date of Birth: ________________ Date of Hire: ________________
Address: _______________________________________________________________________________________
City: ______________________ State: _____ Country: ___________Zip: _________ Phone: _________________
Date of Separation from Active Employment (if applicable): ____________________________________________
Do you currently have an outstanding loan balance in this plan Yes
No
Participant’s Spouse: _____________________________________ Social Security #: _______________________
Print or Type Complete Legal Name – First, MI, Last
My benefits are subject to a court order dividing benefits as a result of a dissolution of marriage. Yes
Citizenship:
U.S. Citizen
U.S Resident Alien
No
Nonresident Alien (Please refer to instructions for this choice)
SECTION 1: TRA DISTRIBUTION PROCESSING FEE
Complete by PLAN ADMINISTRATOR and PARTICIPANT for ALL distributions
EMPLOYER – Verify payment responsibility (NOTE: retirement, death & disability are generally billed to the Company): The
Participant will
will not be responsible for paying the TRA distribution processing fee (if “will not” is checked, TRA will bill
the Company). The processing fee is $____________ (if RUSH add additional $60 to the processing fee except for QDRO requests).
PARTICIPANT - Select the method of payment (if applicable):
A cashier’s check or money order made payable to The Retirement Advantage, Inc. is enclosed.
Deduct the processing fee from the distribution proceeds.
(Subject to investment manager policy – please check with the Plan Administrator before making this election.)
NOTE: If payment cannot be deducted from proceeds and no payment is received, TRA will bill the company.
SECTION 2: REASON FOR WITHDRAWAL
Completed by PARTICIPANT/ALTERNATE PAYEE/BENEFICIARY for ALL distributions
I would like a withdrawal for the following reason (choose ONE of the following):
Separated from Active Employment (date of separation required above):
Termination of Employment – participant is no longer employed with the Employer for reasons other than death,
disability or retirement
Death of a Participant – attach a certified copy of the death certificate and Beneficiary Designation Form to this
form
Permanent Disability – attach documentation of the disability from the attending physician to this form
Retirement – participant must have reached the retirement age specified in the Plan Document
Plan Termination – the Plan has been terminated
In-Service Withdrawal (to the extent allowed by the Plan Document):
Pre-Retirement Withdrawal
Required Minimum Distribution (age 70 ½ and older)
Withdrawal of Employee After-Tax Contributions (no 401(k) deferrals, Roth or employer contributions)
Withdrawal of Rollover Contributions
QDRO – Qualified Domestic Relations Order – must be an approved Qualified Domestic Relations Order
Hardship Withdrawal – Hardship distributions for medical, funeral or education expenses are available to an
individual who is named as a Participant's Plan beneficiary, with the Participant paying the applicable tax on the
distribution. The Participant must suspend making deferral contributions to the Plan and all other Plans
maintained by the Employer for a period of 6 months after receipt of this hardship distribution.
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Request for Distribution Form
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I confirm that I have exhausted all other distribution and loan options, that the reason for the hardship is one of
the following and that the amount requested does not exceed the amount of need (choose ALL that apply):
Payment of un-reimbursed deductible medical expenses incurred by me, my spouse, my dependents or my
Plan beneficiary.
Costs directly related to the purchase of my principal residence (does not include making mortgage
payments). This requires that the residence be purchased – a renovation or remodeling is not a sufficient
reason for this requirement. Furthermore, the residence may not be for a family member or for a second
or vacation home, but must be the primary residence of the participant.
Payments necessary to prevent my eviction from my principal residence or to prevent the foreclosure on the
mortgage of my principal residence.
Payment of post-secondary education tuition, room and board and related educational fees for the next 12
months for me, my spouse, my dependents or my Plan beneficiary.
Payments for burial or funeral expenses for my deceased parent, my spouse, my dependents or my Plan
beneficiary.
Payment of expenses for the repair of damage to my principal residence that resulted from a natural
disaster that would qualify for the casualty deduction under Code Section 165.
The Plan Administrator has determined an immediate and heavy financial need based on the facts and
circumstances (this option available only if the Plan Document does not require that the safe harbor
hardship rule be used)
SECTION 3: ALTERNATE PAYEE OR BENEFICIARY INFORMATION
Completed by BENEFICIARY/ALTERNATE PAYEE for Qualified Domestic Relation Order or
death distributions ONLY
Alternate Payee or
Beneficiary Name: _______________________________________________________________________________
Print or Type Complete Legal Name – First, MI, Last
Social Security #: ___________________________________________________ Date of Birth: ________________
Address: _______________________________________________________________________________________
City: ________________________ State: _____ Country: ____________Zip: ______ Phone: _________________
SECTION 4: WITHDRAWAL ELECTION
Completed by PARTICIPANT for hardship, after-tax or pre-retirement distributions ONLY
Hardship or After-Tax Withdrawal:
As a Participant in the Plan, I hereby apply for a withdrawal in the amount of $________________ (specify an exact
amount; maximum available is only allowed for the purchase of a primary residence) (choose ONE of the following):
Before taxes of 10% have been withheld
After taxes of 10% have been withheld
I DO NOT want to have taxes withheld from my distribution (to the extent allowed; a portion of the distribution
may still be subject to withholding).
Pre-Retirement Withdrawal:
As a Participant in the Plan, I request the following:
A complete distribution – Treat my outstanding Plan loan as follows (choose ONE of the following):
Not applicable – I do not have a loan
Include my Plan loan in my distribution
Do not include my Plan loan in my distribution – I will continue to make loan payments
A partial distribution in the amount of $_______________ (choose ONE of the following):
Before 20% mandatory federal taxes and any applicable required state taxes have been withheld
After the 20% mandatory federal taxes and any applicable required state taxes have been withheld
SECTION 5: VESTING
Completed by PLAN ADMINISTRATOR for non-Plan termination distributions ONLY
Is participant 100% vested? Yes
No
If no, complete the rest of this section.
Number of hours participant worked from original date of hire to the end of the FIRST PLAN YEAR: ______________
Number of hours participant worked during LAST PLAN YEAR (first day of Plan Year through date of term): ____________
Other than the first and last years of employment, did participant work LESS than 1,000 hours in any Plan Year? Yes
No
If “Yes”, please specify the Plan Years in which the Participant worked less than 1,000 hours:
________________________________________________________________________________________
If participant ever terminated prior and was rehired please provide those dates and hours worked in those years:
_______________________________________________________________________________________________
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Request for Distribution Form
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SECTION 6: ADDITIONAL CONTRIBUTIONS
Completed by PLAN ADMINISTRATOR for ALL distributions
Choose ONE of the following:
No Additional Contributions – The Participant’s last contribution for payroll ending ______________ was
deposited on approximately ______________.
Date
Date
Additional Contributions – The additional contributions listed below for the payroll periods ending
____________ will be deposited on approximately ______________ (paperwork is held until payroll is deposited)
Date
Date
Deferral
$__________________
Employer $__________________
Match
$__________________
Loan Payment
$__________________
SECTION 7: BENEFIT ELECTION
Completed by PARTICIPANT/ALTERNATE PAYEE/SPOUSAL BENEFICIARY for distributions
other than non-spousal distributions ONLY
Please make a benefit election below. The availability and compliance of the election you choose will be verified in
accordance with the Plan Document and IRS provisions. Please see the Special Tax Notice for information on
withholding. It is recommended that you contact the Plan’s investment agent or representative regarding your
investment options. Note that Roth 401(k) deferral rollovers can only be made to a Roth IRA or a qualified plan with a
Roth provision.
Paid to Me in the Following Form (choose ONE of the following):
Lump Sum (If you are electing a hardship withdrawal, Lump Sum is your only option)
Total Fed. Withholding _________% (Use only for amounts greater than the 20% mandatory withholding)
Total State Withholding _________% (Subject State Regulations and/or investment manager policy)
Partial Withdrawal (only if allowed by the Plan Document)
Installments (only if allowed in the Plan Document)
Qualified Annuity Benefit – (only if allowed in the Plan Document)
See the Request for Distribution Form Instructions for an explanation of the Qualified Annuity Benefit
(choose ONE of the following):
Joint and 50% Survivor Annuity
Joint and 75% Survivor Annuity
Joint and 100% Survivor Annuity
Paid to Me as a Lump Sum and Direct Rollover - Complete rollover information below*
Amount to be paid to me is $________________, with the remainder (at least $500) to be rolled over (choose from
of the following):
Before taxes are withheld
After taxes are withheld
Total Fed. Withholding _________% (Use only for amounts greater than the 20% mandatory withholding)
Total State Withholding _________% (Subject to State Regulations and/or investment manager policy)
Direct Rollover - Complete rollover information below*
I am electing a direct rollover from this Plan (distribution amount must be at least $200) to (choose ONE of the following):
Another qualified Plan
Another qualified plan with a Roth option for Roth 401(k) deferral rollovers
An IRA (Do not forward IRA set-up forms to TRA)
A Roth IRA (Do not forward IRA set-up forms to TRA)
*Rollover Information: (unless otherwise directed by the Plan’s investment manager, rollover check’s will be sent
directly to the participant)
Name of IRA or Qualified Plan: ____________________________________________________________________
Name of Roth IRA or Qualified Plan with Roth: _______________________________________________________
Make Check Payable To: __________________________________________________________________________
Account Number:__________________________________ Contact Person:________________________________
Address:_______________________________________________________________________________________
City:_______________________________ State:______ ZIP:___________ Phone:___________________________
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Request for Distribution Form
SECTION 8: ELECTRONIC FUND TRANSFER
Completed by PARTICIPANT
Only offered for plans with Guardian (greater than $5,000), Hartford, ING, John Hancock, Nationwide and Verisight
Please submit a copy of a voided check for all EFT requests
Please note that mandatory federal and state withholding applies to EFT’s.
Account #_________________________________ Routing #_______________________________________
Exact name as it appears on bank account __________________________________________________________
(Participant must be single or joint owner of account)
Bank Account Type:
Checking
Savings
Bank Name: ____________________________________________________________________________________
Address: _______________________________________________________________________________________
City: ____________________ State: _______ Country: _________Zip: __________ Phone: ___________________
If this section is not fully completed, a check will be issued.
SECTION 9: BENEFIT ELECTION FOR NON-SPOUSAL BENEFICIARIES
Completed by NON-SPOUSAL BENEFICIARIES for non-spousal beneficiary distributions ONLY
Please make a benefit election below. The availability and compliance of the election you choose will be verified in
accordance with the Plan Document and IRS provisions. Please see the Special Tax Notice for information on
withholding. It is recommended that you contact the Plan’s investment agent or representative regarding your
investment options.
Lump Sum Payment of the Death Benefit (choose ONE of the following):
Total Fed. Withholding _________% (Use only for amounts greater than the 20% mandatory withholding)
Total State Withholding _________% (Subject to State Regulations and/or investment manager policy)
Paid to Me as a Lump Sum and Direct Rollover – Complete rollover information below
Amount to be paid to me is $________________, with the remainder (at least $500) to be rolled over (choose ONE
of the following):
Before taxes are withheld
After taxes are withheld
Total Fed. Withholding _________% (Use only for amounts greater than the 20% mandatory withholding)
Total State Withholding _________% (Subject to State Regulations and/or investment manager policy)
Direct Rollover to Inherited IRA – Complete rollover information below
Rollover Information: (Rollovers into an Inherited IRA must be a direct Trustee to Trustee transfer)
Name of Inherited IRA:_____________________________________________________________________________________
Name of Inherited Roth IRA (for Roth money):_________________________________________________________________
Make Check Payable To: _________________________________________________________________________
Account Number: ____________________________ Contact Person: ____________________________________
Address: ______________________________________________________________________________________
City: __________________________________ State: __________ Zip: __________ Phone: ___________________
SECTION 10: PLAN LIFE INSURANCE ELECTION
Completed by PARTICIPANT/ALTERNATE PAYEE/BENEFICIARY for ALL distributions
Not Applicable (choose ONE of the following):
I do not have life insurance in the Plan
This is a Qualified Domestic Relations Order distribution
This is a death distribution – The face value of the policy will be distributed
Participant Separated from Active Employment (choose ONE of the following):
Continue policy – Continue the policy by transferring ownership of the policy from the Plan to me. I
understand that future premiums will be billed to me.
Surrender Policy – Surrender the policy for net cash surrender value, combine it with the remainder of my
Plan assets and distribute as directed above. I understand that coverage will cease immediately.
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Request for Distribution Form
Participant Still Actively Employed (choose ONE of the following):
Maintain Existing Policy – Maintain my policy as it currently exists.
Continue Policy with no Further Payments – Stop all future premium payments for policy and place on an
extended term basis. I understand that the coverage will cease when the premium payments exceed the
available cash value
Surrender Life Insurance Policy (NOT available for hardship distributions) – Surrender the policy for any net
cash surrender value, combine it with the remainder of my Plan assets and distribute as directed above. I
understand that coverage will cease immediately.
Surrender Life Insurance Policy and Combine with other Plan assets – Surrender the policy for any net
cash surrender value and combine with the remainder of my Plan assets. I understand that coverage will
cease immediately and that if there is a net cash surrender value to my policy at the time of surrender, I
will be required to deposit such amount into my Plan account.
SECTION 11: REQUIRED SIGNATURES
Complete for ALL distributions
I understand that the investment manager may impose a charge to complete this distribution and/or may restrict the
completion of all or a portion of this distribution. I have read and understand the instructions for this form, including the
Special Tax Notice. I understand that applicable federal tax withholding will be made and that mandatory state
withholding may also apply. I have at least 30 days to consider my payment options. By returning this completed form
before the end of the 30-day election period, I am waiving the remainder of the 30 days.
If, following the distribution, but no more than 180 days from the date I executed this Request for Distribution Form, the
Plan Administrator determines I am eligible for an additional allocation of earnings, forfeitures or employer contributions,
the Plan Administrator will treat this consent to the distribution as applicable to the subsequent allocation and will make
a subsequent distribution of such amounts in accordance with this election.
I understand if 180 days has passed since I signed this election form, I will be required to submit a new election form
which will restart the time limit described above.
For annuity provisions, if I affirmatively elect a benefit payment option other than the Qualified Annuity Benefit, I have
the right to revoke that election until the annuity starting date, or if later, for at least seven days after I receive the
Qualified Annuity Benefit Notice (as included in the Request for Distribution Form Instructions). If applicable, I hereby
elect to waive the qualified joint and survivor annuity and pre-retirement survivor annuity forms of payment.
The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid back up withholding.
Certification required of U.S. persons only (including U.S. citizens or U.S. resident aliens)
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number, and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I
have not been notified by the Internal Revenue Service (IRS) that I am subject to backup
withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me
that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person or a U.S resident alien (as defined by the IRS instructions
for Form W-9)
Certification Instructions
By checking this box you are admitting you have been notified by the IRS that you are currently
subject to backup withholding because you have failed to report all interest and dividends on your tax
return.
This plan is an account held in the United States which means you are not required to provide a code
indicating that you are exempt from FATCA reporting.
_________________________________________________________________
Participant / Beneficiary / Alternate Payee - Please Print Name
_________________________________________________________________
Participant / Beneficiary / Alternate Payee - Signature
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_____________________
Date
Request for Distribution Form
_________________________________________________________________
Plan Administrator Name – Please Print Name
_________________________________________________________________
Plan Administrator - Signature
(Required for ALL Distributions)
_____________________
Date
If the Plan does not have annuity provisions and/or the participant is not married, please check here:
SPOUSAL CONSENT IS NOT APPLICABLE
If the Plan has annuity provisions, spousal consent must be given below:
Spousal Consent
I hereby consent to the foregoing election made by my spouse, to have benefits under the Plan paid in
the form specified herein. I understand that in consenting to this distribution, I may be reducing or
eliminating benefits that I may otherwise be legally entitled to at a later date and that this consent is
irrevocable unless my spouse revokes the waiver before benefits begin.
_________________________________________________________
Spouse Signature
______________________
Date
Witnessed by:
_________________________________________________________
[ ] Notary Public Signature & Seal OR [ ] Plan Administrator Signature
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______________________
Date
Request for Distribution Form
DID YOU REMEMBER TO…
Read the Request for Distribution Form Instructions, Special Tax Notice and Postponement of Distribution Election?
Include the appropriate processing fee?
Obtain Participant/Beneficiary/Alternate Payee signature?
Obtain Spousal consent (if needed)?
Obtain Plan Administrator signature?
Have the Plan Administrator complete Section 1, Section 5, Section 6, and Section 11?
Completed forms can be sent to TRA by fax at (800)459-5815, email at [email protected],
or mailed to 47 Park Place Suite 850, Appleton WI 54914-8233
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Request for Distribution Form