Payment Election and Distribution Balance Form
Use this form to record payment election details and distribution balance information for a distribution request. The title must remain exactly "Payment Election and Distribution Balance Form" throughout the form.
Participant and Record Details
Participant Full Name
*
First Name
Middle Name
Last Name
Employer or Plan Name
*
Participant or Member ID (last 4 digits only)
Statement or Reporting Period
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Payment Election
Payment election method
*
Direct deposit
Mailed check
Other permitted distribution method
Amount or percentage to apply
*
Election effective date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Distribution Balance Details
Current Balance Available for Distribution
*
Requested Distribution Amount
*
Notes or Special Handling Instructions
Submit Form
Should be Empty: