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
(mm/dd/yyyy)
Date of Hire

Month Day Year
(mm/dd/yyyy)
Marital Status *

Not Married Married - Spouse Name:
If resigned from your prior employer (above), please indicate new employer, if any
A valid photo ID must be attached to this request.

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Cancel of
Please select one of the reasons for distribution below: *

Disability (Additional certification required) In-Service Distribution (as permitted by the plan document) Death Benefit Payout (Please provide death certificate) Termination of the Plan
Please provide additional supporting document

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Cancel of
Please provide death certificate

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Cancel of
Retirement/Separation of Employment
Date of Hire

Month Day Year
(mm/dd/yyyy)
Date of Termination

Month Day Year
(mm/dd/yyyy)
Hours Worked this Plan Year
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 $ or % 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 / IRA Account Name
Plan Account Number
Check Mailed To:

Mailing Address

City State / Territory

Postal / Zip Code
B. Request for a Rollover to an IRA
I would like to rollover $ blanks or % 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
Check Mailed To:

Mailing Address

Mailing Address Line 2

City State / Territory

Postal / Zip Code
C. Request for a Direct Payment to You
Please issue a distribution paid directly to me equal to $ Gross Amount Net Amount or % 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 / Territory

Postal / Zip Code
Bank Name
Type of Account

Savings Checking
Savings Account #
ABA Routing #
Checking Account #
ABA Routing #
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.
Attach voided check or bank statement

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Cancel of
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
Primary Contact Number
Please enter a valid phone number.
Alternate Contact Number
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
mm/dd/yyyy
Should be Empty:

RETIREMENT PLAN DISTRIBUTION FORM

General Information

Retirement/Separation of Employment

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: