IRA Distribution Request Form

ASC IRA DISTRIBUTION FORM
Employer / Plan Name
Employer / Plan Name
The following documents must be submitted in order to process your request. If documents are incomplete upon submission, all documents will need to be re-submitted.
- This form, completed and signed
- If loan amount is to be sent to you electronically (via ACH), provide a voided check or letter from your bank on bank letterhead with your name, routing number, account number, and account type (checking or savings)
- A valid photo ID, such as Driver's License or Passport
General Information
Your Name*

First Name Middle Initial Last Name
Your Name 2

First Name Middle Name Last Name
Social Security Number*
Social Security Number
Date of Birth*

MonthDay Year
Date
Mailing Address*

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

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Contact Number*

Area Code Phone Number
Alternative Contact Number

Area Code Phone Number
Email Address*
example@example.com
Marital Status:

Not MarriedMarried
Spouse Name*
*Common Law is NOT recognized as legal marriage.
Type of Distribution*

Request for a Rollover to Your Next EmployerRequest for a Rollover to an IRADeath Benefit PayoutRequest for a Direct Payment to You
Request for a Rollover to Your Next Employer
I would like to rollover $ or % of my vested balance to a 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.
Trustee / Financial Institution / Plan Name*
Plan Account Number:
Check Mailed To: *

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

Street Address Line 2

City State / Province

Postal / Zip Code
Request for a Transfer to an IRA

(Roth or Traditional Individual Retirement Account)
I would like to rollover $ or % of my vested balance to an IRA*. Please transfer my account balance to the following IRA Account, please debit my account $50.00 for processing.
Type of Account:*

Traditional (Pre-Tax)ROTH (After-Tax)
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

City State / Province

Postal / Zip Code
Death Benefit Payout
Death of Account Owner - Death Benefit payment will be made to (select one):*

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

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

MonthDay Year
Date
Mailing Address*

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

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Contact Number*

Area Code Phone Number
Alternative Contact Number

Area Code Phone Number
Email Address
example@example.com
Request for a Direct Payment to You
Please issue a distribution paid directly to me equal to $ (NET CHECK) or % of my account.
WITHHOLDING TAX: If no election is made, ASC is required to withhold 10% of your gross distribution for payment of income tax. U.S. Citizens who are foreign residents are subject to a 10% minimum withholding rate. Nonresident aliens are subject to either the minimum tax treaty rate or a 30% tax withholding rate and must submit a valid IRS Form W -8BEN. Please see the Special Tax Notice for details.
*

10% will be withheld for the payment of income tax, unless another amount is indicated:Do not withhold tax, I am responsible for the tax on my distribution upon tax filing.
    ENTER AMOUNT
Processing Fee*

I understand that there is a $50.00 processing fee. However, if I have taken a distribution within last calendar year the processing fee is $10.00.
Payout Method*

I would like a check issued to me.I would like a direct deposit (ACH) to my bank account. I have attached a voided check or bank statement that contains the valid routing number and bank account number. I have also provided my physical address as required by the bank.
Is your physical address the same as your mailing address?*

YesNo
Physical Address*

Physical Address - Required for Direct Deposit

Street Address Line 2

City State / Province

Postal / Zip Code
Physical Address

Physical Address - Required for Direct Deposit

Street Address Line 2

City State / Province

Postal / Zip Code
Bank Name*
Type of Account*

SavingsChecking
Bank Account #*
ABA Routing #*
Bank Account #*
ABA Routing #*
By electing a Direct Deposit (ACH), 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.
Attach VOIDED Check or Original Bank Statement Here*

Browse Files

Cancelof
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 will relieve the Trustee of any liability (subject to terms of the account). I have also read the “Special Tax Notice Regarding Plan Payments” and understand that I will be liable for paying where State Tax will be withheld, if the taxes owed on this distribution at year end when my income taxes are filed unless I elect a Direct Rollover of my “eligible rollover distribution” 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*

Browse Files

Cancelof
The following documents must be submitted in order to process your loan request. If documents are incomplete upon submission, all documents will need to be re-submitted.
- This form, completed and signed
- If loan amount is to be sent to you electronically (via ACH), provide a voided check or letter from your bank on bank letterhead with your name, routing number, account number, and account type (checking or savings)
- A valid photo ID, such as Driver's License or Passport
Signature of Participant*

Clear
Date*

MonthDay Year
Date
Should be Empty:

ASC IRA DISTRIBUTION FORM

General Information

Request for a Rollover to Your Next Employer

Request for a Transfer to an IRA

Death Benefit Payout

Request for a Direct Payment to You