NMI In-Service Plan Distribution Form

NMI In-Service Plan Distribution Form
General Information
Government Agency Name*
Government Agency Name
Your Name (Last Name, First Name)*

Last NameFirst Name
Your Name (Last Name, First Name)

Last NameFirst Name
Social Security Number*
Social Security Number
Address*

Mailing Address

Street Address Line 2

CityState/Territory

ZIP
Contact Number*
Format: (000) 000-0000.
Alternate Contact Number
Format: (000) 000-0000.
E-mail Address*
example@example.com
Not MarriedSpouse Name:
A valid photo ID must be attached to this request*

Cancelof
A. Request for a Rollover to Your Next EmployerB. Request for a Rollover to an IRAC. Request for a Direct Payment to You
A. Request for a Rollover to Your Next Employer
I would like to rollover $ dollar amount or percent amount % 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 $25.00 for processing.
Check Payable: Trustee / Third Party Administrator / Plan Name
Plan Account Number
Check Mailed to: Mailing Address

Mailing Address

Street Address Line 2

CityState / Territory

ZIP
B. Request for a Rollover to an IRA
I would like to rollover $ dollar amount or percent amount % of my vested balance to a Traditional IRA Roth IRA
Please waive all fees. I would like to Rollover my Balance to the ASC Trust IRA Program. With this, please transfer my existing account balances into my own personalized account using the same or like investment options as I am currently invested in. ASC Trust will send me the appropriate paperwork on my account.I would like to transfer my account balance to the following IRA Account, please debit my account $25.00 for processing.
Check Payable: Trustee / Third Party Administrator / IRA Account Name
IRA Account Number
Check Mailed To: Mailing Address

Mailing Address

Street Address Line 2

CityState / Territory

Postal / Zip Code
C. Request for a Direct Payment to You
Please issue a distribution paid directly to me equal to $ dollar amount or percent amount % of my vested balance. I understand that there is a $25.00 processing fee for distribution.
I would like a check issued to me.I would like an automatic deposit to my bank account (ACH). By electing payout by ACH, I understand and agree to all ACH rules. I have attached a bank certification or voided check that contains the valid ACH routing number and bank account number.
Name of Bank
Savings AccountChecking Account
Savings Account #
Routing #
Checking Account #
Routing #
Attach a bank certification or voided check

Cancelof
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.
Certification:

I have read this payment request and affirm that the above information and elections made are accurate and may any payments made by the Trustee pursuant to the above (subject to terms of the plan of the above name employer) 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". I certify that the above information is true and correct to the best of my knowledge.
Signature of Participant or Beneficiary*
Date*

MonthDayYear
Date
Date of Birth (mm/dd/yy)

MonthDayYear
Date
Date of Hire (mm/dd/yy)

MonthDayYear
Date
NMI Defined Contribution Plan

Social Security Acknowledgement Form
Verification of Understanding

By signing this form, you confirm that you have received a copy of the Social Security-Retirement handout and that you understand that taking a distribution prior to retirement may have adverse effects on your ability to retire.
Employee Signature*
Date*

MonthDayYear
Date
Should be Empty:

NMI In-Service Plan Distribution Form

General Information

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

Certification:

NMI Defined Contribution Plan

Verification of Understanding