Required Minimum Distribution (RMD) Request Form

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PLEASE DETACHFinancial Advisor Information (if any)()-()-Name of Financial AdvisorPhone NumberFAX number (if any)(Not applicable to Roth IRAs or Coverdell Education Savings Accounts.)PARTICIPANT INFORMATION (Please Print)////Participant s Name Birthdate ( Required )Soc. Sec.#Street Address ( Check here if new address*)CityStateZipAccount Number(s) (The Distribution method you elect below will be applied to all accounts, unless you indicate otherwise.)*Signature Guarantee Required for distributions to new Minimum Distribution (RMD) Request FormIf this is a Profit Sharing or Money Purchase Pension Plan, the Plan Employer must sign the Certification on the reverse OF Distribution Balance of Account Partial Payment of:$________________; _____% of Account; or ___________ Shares Periodic Payments: Monthly Quarterly AnnuallyBeginning:/ / 20(Dividends & Capital Gains will automatically reinvest.)

if this is a profit sharing or money purchase pension plan, the plan employer must sign the certification below. i. employer’s certification

  Distribution, Request