QP/401(k) Separation From Service Distribution Request Form 2007-2025 free printable template

Page 1 of 2 2007 Ascensus Inc. Using the QP/401 k Separation From Service Distribution Request Form Your plan permits you to withdraw your vested account balance when you separate from service with your employer due to termination disability or separated from service for one of those reasons and you would like a distribution of all or a portion of your vested account balance please read the instructions below and complete the Separation From Service Distribution Request Form that accompanies...these instructions. Authorization You must authorize this distribution by signing and dating the Separation From Service Distribution Request Form. Please verify that all information provided by the participant is accurate and complete. I instruct the plan administrator to authorize this distribution from the plan as soon as administratively possible. Signature of Participant Date Plan Administrator Use Only Date of Separation From Service Reason for Separation From Service Termination...Attainment of Normal Retirement Age Disability NOTE To process this request in the most efficient manner please utilize the website at This form may not be used to request a distribution in the form of installment or annuity payments. Signature of Participant Date Plan Administrator Use Only Date of Separation From Service Reason for Separation From Service Termination Attainment of Normal Retirement Age Disability NOTE To process this request in the most efficient manner please utilize the...website at This form may not be used to request a distribution in the form of installment or annuity payments. If a participant requests a distribution in either of those forms of payment please contact your Client Service Representative for further instructions. 10486 12/2007 QP/401 k Separation From Service Distribution Request Form This form may be used if you have separated from service due to termination disability or attainment of normal retirement age and you wish to withdraw funds from...the plan. PARTICIPANT INFORMATION Social Security Number First Name Last Name Address City State Zip Check this box if your address has changed since you received your last participant statement with respect to the plan. DISTRIBUTION INSTRUCTIONS NOTE Refer to your summary plan description to determine whether installment and/or annuity payments are available to you in addition to those types of distributions listed below. You acknowledge that the participant s vested account balance will be...calculated based on the data you have provided. Please sign and date the form to acknowledge that you acting as a named and authorized representative of the plan confirm that the information provided is complete and accurate and the request is in accordance with this plan. If the participant is married you acknowledge that you have reviewed the Participant Distribution Consent of Spouse Form if applicable and have found it to be in good order. In addition you acknowledge that the participant has...taken the required minimum distribution if applicable prior to your authorization of a direct rollover. Finally you authorize this request to be processed as instructed. 10482NR-BD 5/2008 QP/401 k DISTRIBUTION NOTICE Important Information About Your Qualified Retirement Plan Distribution As a participant in your employer s qualified retirement plan you have accumulated a vested account balance. Enter the date the participant separated from service and the reason for the separation from service....You acknowledge that the participant s vested account balance will be calculated based on the data you have provided. Please sign and date the form to acknowledge that you acting as a named and authorized representative of the plan confirm that the information provided is complete and accurate and the request is in accordance with this plan. If the participant is married you acknowledge that you have reviewed the Participant Distribution Consent of Spouse Form if applicable and have found it to...be in good order. In addition you acknowledge that the participant has taken the required minimum distribution if applicable prior to your authorization of a direct rollover. The additional 10 percent tax generally does not apply to 1 payments that are paid after you separate from service with your employer during or after the year you reach age 55 2 payments that are paid because you retire due to disability 3 payments that are paid as equal or almost equal payments over your life or life...expectancy or your and your beneficiary s lives or life expectancies 4 dividends paid with respect to stock by an employee stock ownership plan ESOP as described in Section 404 k of the Code 5 payments that are paid directly to the government to satisfy a federal tax levy 6 payments that are paid to an alternate payee under a qualified domestic relations order 7 payments that do not exceed the amount of your deductible medical expenses or 8 payments that are paid to you as a qualified military...reservist. See IRS Form 5329 for more information on the additional 10 percent tax. The additional 10 percent tax will not apply to distributions from a governmental 457 b plan except to the extent the you reach age 591 2 unless one of the exceptions applies. SPECIAL TAX TREATMENT IF YOU WERE BORN BEFORE JANUARY 1 1936 lump sum distribution it may be eligible for special tax treatment.