401(k) Plan Termination Distribution Request

Participant Full Name

First NameLast Name

Participant Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Plan Name

Employer Name (at time of plan termination)

Employment Status at Termination

Other

Distribution Option

Federal Tax Withholding Election

State Tax Withholding Election (if applicable)

Distribution Delivery Method

If selecting wire transfer, provide receiving institution name and instructions

Additional Comments or Special Instructions

Participant Signature