| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

disclaimer is generally any statement intended to specify or delimit the scope of rights and obligations that may be exercised and enforced by parties in a legally recognized relationship.  

1. Account Information

Beneficiary Details

2. Distribution Type
Complete one of the following groups below*

3. Distribution Details

RMD’s are not processed on a recurring basis

 from my payment(s) OR
from my payment(s)

from my payment(s)

*A current Fair Market Value must be provided to distribute assets in-kind
**This recurring distribution will remain in effect until you provide a written request to cancel or change. Recurring distribution payments incur a $25 fee per distribution.
5. Funding Instructions

For ACH/WIRE – Please complete the info below

For Check – Please complete the info below

6. Signatures and Acknowledgement
The distributions you receive from your individual qualified account established at this institution are subject to federal income tax withholding unless you elect not to have withholding apply. You may elect not to have withholding apply to your distribution payments by completing the "Withholding Election" section above. If you do not complete the "Withholding Election" section by the date your distribution is scheduled to begin, federal income tax will be withheld from the amount withdrawn at a rate of 20%. If you elect not to have withholding apply to your distribution payments, or if you do not have enough federal income tax withheld from your distribution, you may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient.

I certify that I am the proper party to receive payment(s) from this 401k, and that all information provided by me is true and accurate. I acknowledge that I have read the Notice of Withholding and have completed the Withholding Election above. I further certify that no tax advice has been given to me by the Administrator, Custodian, or Trustee, that distributions (except certain transfers) are reported to the IRS, and that all decisions regarding this withdrawal are my own. I expressly assume the responsibility for any adverse consequences which may arise from this withdrawal and I agree that the Administrator, Custodian, Trustee shall in no way be responsible for those consequences.

The above request is hereby approved, and the Administrator is authorized to distribute the participant’s benefits in accordance with such request.