ASC Micronesia Distribution Form

RETIREMENT PLAN DISTRIBUTION FORM
General Information
Employer / Plan Name *
Employer / Plan Name
Name *

First Name Last Name
Name

First Name Last Name
Social Security Number *
Social Security Number
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address *
example@example.com
Home Phone *
Please enter a valid phone number.
Cell Phone *
Work Phone
Other Phone
Date of Birth *

Month Day Year
Date
Date of Hire *

Month Day Year
Date
Marital Status *

Not Married Married
Spouse Name

First Name Last Name
If resigned from your prior employer (above), please indicate new employer, if any
A valid photo ID must be attached to this request. *

Cancel of
Reason for Distribution
Type of Request *

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
A. Request for a Rollover to Your Next Employer
I would like to rollover $ blanks* or blank* % of my vested balance to another qualified retirement plan.
Select one of the following: *

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 *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
B. Request for a Rollover to an IRA
I would like to rollover $ blanks* blank* % of my vested balance to an IRA.
Select one of the following: *

Please waive all fees. I would like to rollover my balance to the ASC Trust IRA Rollover Program. I have attached the ASC IRA enrollment form as required for this transaction. I would like to transfer my account balance to the following IRA, please debit my account $50.00 for processing.
Check Payable: Trustee / Financial Institution / IRA Account Name *
Plan Account Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
C. Request for a Direct Payment to You
Please issue a distribution paid directly to me equal to $ blanks* Gross Amount Net Amount* or blank* % of my vested balance. I understand that there is a $50.00 processing fee for distributions.
Select one of the following: *

I would like a check issued to me. I would like a 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.
Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Bank Name *
Type of Account *

Savings Checking
Bank Account # *
ABA Routing # *
Bank Account # *
ABA Routing # *
Attach VOIDED Check Here *

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

Beneficiary - Spouse Beneficiary - Non Spouse Alternate Payee (resulting from court order)
Beneficiary / Payee Name (Last Name, First Name) *
Social Security Number *
Date of Birth (mm/dd/yyy) *

Month Day Year
Date
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Number(s) *
Please enter a valid phone 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 certify that the above information is true and correct to the best of my knowledge.
Signature of Participant *

Clear
Date *

Month Day Year
Date
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

Certification: