Retirement Plan Distribution Form

Retirement Plan Distribution Form
A copy of a valid government issued photo identification is required to process this request.

If you elect to receive this request as a direct deposit/ACH, attach a voided check or bank statement that contains the valid routing number and bank number.

Incomplete submissions will not be accepted.
Please read the attached "Special Tax Notice Regarding Plan Payments" before completing this form.
General Information
Employer / Plan Name*
Employer / Plan Name 2
Your Name*

First NameLast Name
Name 2

First NameLast Name
Social Security Number*
Social Security Number 2
Mailing Address*

Mailing Address (Street Address, P.O. Box, etc.)

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Date of Birth (mm/dd/yyy)*

MonthDayYear
Date
Date of Hire (mm/dd/yyy)*

MonthDayYear
Date
Home Phone*
Cell Phone*
Work Phone
Other Phone
Marital Status:*

Not MarriedMarried
Spouse Name:
*(Common Law is NOT recognized as legal marriage)
*If resigned from your prior employer (above), please indicate new employer, if any:
Reason for Distribution
Please select ONE of the reasons below:*

Retirement/Separation of Employment (From current employer or any controlled group of companies that your employer is a part of)Disability (Additional certification required)In-Service Distribution (As permitted by the plan document)Death Benefit Payout (Please provide death certificate)Termination of the Plan
Date of Hire (mm/dd/yyyy)

MonthDayYear
Date
Date of Termination (mm/dd/yyyy)

MonthDayYear
Date
Hours Worked this Plan Year
Attach Supporting Document Here

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Type of Distribution*

A. Request for a Rollover to Your Next EmployerB. Request for a Rollover to an IRAC. Request for a Direct Payment to YouD. Death Benefit Payout
A. Request for a Rollover to Your Next Employer
I would like to rollover $ or % of my vested balance to another qualified retirement plan*.
My new employer has a plan maintained by ASC, please waive all fees associated with this distribution.My new employer's plan is not maintained by ASC, please debit my account $50.00 for processing.
Check Payable: Trustee / Financial Institution / Plan Name
Plan Account Number
Check Mailed To:

Mailing Address (Street Address, P.O. Box, etc.)

Street Address Line 2

CityState / Province

Postal / Zip Code
B. Request for a Rollover to an IRA

(Roth or Traditional Individual Retirement Account)
I would like to rollover $ or % of my vested balance to an IRA*.
*Type of account:

Traditional (Pre-Tax)ROTH (After-Tax)
Choose ONE below:

Please waive all fees. I would like to rollover my balance to the ASC Trust IRA Rollover Program.I would like to transfer my account balance to the following IRA, please debit my account $50.00 for processing.
Attach ASC IRA Enrollment Form Here

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I have attached the ASC IRA Enrollment Form as required for this transaction.In the absence of an Enrollment Form, I would like to keep my investments in the same funds if available to the IRA.Otherwise, invest my account in to the Target Date Profile (TDP) in accordance with my age.
Check Payable: Trustee / Financial Institution / Plan Name
Plan Account Number
Check Mailed To:

Mailing Address (Street Address, P.O. Box, etc.)

Street Address Line 2

CityState / Province

Postal / Zip Code
C. Request for a Direct Payment to You
Please issue a distributions paid directy to me equal to $
I understand that there is a $50.00 processing fee for distributions.
Gross AmountNet Amount
or % of my vested balance.
I understand that there is a $50.00 processing fee for distributions.
I would like a check issued to me.I would like to deposit (ACH) to my bank account. I have attached a voided check or bank certification that contains the valid routing number and bank account number. I have also provided my physical address as required by the bank.
Phyiscal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BANK NAME:
Choose ONE below:

Savings AccountChecking Account
Savings Account Number:
Routing Number:
Checking Account Number:
Routing Number:
By electing a Direct Deposit (ACH) and by signing below, I hereby authorize ASC TRUST LLC 1.) to initiate credit entries to the depository financial institution named above 2.) to initiate debit entries to adjust for processing errors. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.

Further, I understand that my distribution may be subject to 20% Mandatory Federal Income Tax Withholding. Read the Special Tax Notice for more details.
Attach Voided Check or Bank Certification Here*

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D. Death Benefit Payout
Death of Account Owner - Death Benefit payment will be made to (select one):

Beneficiary - SpouseBeneficiary - Non SpouseAlternate Payee (resulting form court order)
Beneficiary / Payee

First NameLast Name
Social Security Number
Date of Birth (mm/dd/yyyy)

MonthDayYear
Date
Address

Mailing Address (Street Address, P.O. Box, etc.)

Street Address Line 2

CityState / Province

ZIP
Contact Number(s)

Area CodePhone Number
Email Address
example@example.com
Certification: I have read this payment request and affirm that the above information and elections made are accurate and any payments made by the Trustee pursuant to the above (subject to terms of the Plan) will relieve the Trustee of any liability. I have also read the "Special Tax Notice Regarding Plan Payments", and understand that Federal Tax will be withheld at 20% on the taxable portion unless I elect a Direct Rollover of my "eligible rollover distribution" State Tax will be withheld, if applicable. I certify that the above information is true and correct to the best of my knowledge.
A valid photo ID must be attached to this request*

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Signature or Participant*

Clear
Date

MonthDayYear
Date
*If you have requested less than 100% of your vested balance to be rolled over, the remainder of your distribution will be issued as a separate check made payable to you with Federal Taxes Withheld at 20% on the taxable portion. State taxes will be withheld, where applicable.
Should be Empty:

Retirement Plan Distribution Form

General Information

Reason for Distribution

A. Request for a Rollover to Your Next Employer

B. Request for a Rollover to an IRA

C. Request for a Direct Payment to You

D. Death Benefit Payout