CMI 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.
Employer/Plan Name: Continental Micronesia, Inc. 401(k) Savings Plan
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
Contact Number*
Alternate Contact Number*
Email*
example@example.com
Marital Status:*

Not MarriedMarried
Married - Spouse Name:
I will be filing this year's income taxes in:

Guam (Rev & Tax)U.S. (IRS)CNMI (DRT)
Date of Birth (mm/dd/yyy)*

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

MonthDayYear
Date
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 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*.
Choose ONE below

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 $15.00 for check processing or $10.00 ACH.
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 $ dollar amount or percent amount % 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. With this, please transfer my existing account balances into my own personalized account using the same 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, please debit my account $15.00 for the processing of a check.
Check Payable: Trustee / Financial Institution / IRA Account 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.
Choose ONE below

I would like a check issued to me. I understand that there is a $15.00 check processing fee for distributions.I would like an automatic deposit to my bank account (ACH). I have attached a deposit slip or voided check that contains the valid routing number and bank account number. I understand that there is a $10.00 ACH processing fee for distributions.
BANK NAME:
Choose ONE below:

Savings AccountChecking Account
Savings Account Number:
Routing Number:
Checking Account Number:
Routing Number:
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 Continental Micronesia, Inc. 401(k) 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.
Attach Voided Check Here*

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A valid photo ID must be attached to this request*

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Cancelof
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

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