Tax Deferred Solutions

457 PLAN DISBURSEMENT REQUEST FORM

Step 1 of 3: Supply Information | Step 2 of 3: Confirm Entries | Step 3 of 3: Submission Confirmation

Please supply the information requested below.
Read all agreements on this form before submitting.
Fields having an asterisk notation are required.

Transaction Type:

*Type:

Cash or rollover disbursement from Plan with a qualifying event. Qualifying events are either of the following;
At or over the minimum age for a distribution (70 1/2 or 59 1/2 years of age depending on your plan's features)
Separation from service
For more details, please visit our Transaction Information page or contact Tax Deferred Solutions.

Employee Information

Last Name: First Name: MI:
Maiden/Former Name:
* Address:
* City:		* State:	* Zip:
* Phone:		Alternate Phone:
* Email:		* Re-enter Email:
* SS#:	(9 digits, no dashes or spaces)	* Date of Birth: (MM/DD/YYYY)
Date of Separation:

Service Provider Agent Information:

There is a financial advisor/representative associated with this transaction.

Distributing Account Information:

Please provide the information for the employer from whose Plan you wish to withdraw funds:

*Employer Name:	Current Employer Name (if different than account sponsor):

Please provide the following information for the Service Provider who will be distributing (paying out) the funds for this transaction:

*Distribution Qualification:

*Service Provider Company:
If other, please supply company name here:
Account #:

*Amount Requested:

Receiving Account Information:
Please provide the following information for the Service Provider who will be receiving the funds for this transaction:

This will be a cash distribution. No receiving Service Provider is involved.

* Service Provider Company:
If other, please supply company name here:
Account #:
* Account Type:

Confirmation:
By clicking the button below labeled "Continue", I hereby confirm that the information on this form is correct and complete to the best of my knowledge.

*Re-enter Social Security # to verify:

Additional instructions will appear on the next screen

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