Transcription of Death Benefit Claim Request 401(k) Plan State of …
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Death Benefit Claim Request 401(k) Plan State of …
Death Benefit Claim Request 401(k) Plan Refer to the Death Benefit Claim Guide while completing this form. Use blue or black ink only. A certified Death certificate must accompany this form. State of Tennessee 401(k) Plan 98986-02. Decedent's Information Last Name First Name MI Social Security Number City, State and Country of Legal Domicile at Time of Death Account Extension (if applicable). Mo Day Year Mo Day Year Date of Birth Date of Death Claimant's Information Specify Claimant's relationship to the decedent: Last Name First Name MI Has this account already been transferred to the Claimant?
][Form 23 ][GWRS FDEATH ][10/29/12 ][Page 1 of 18][RIVK][/302410330][A01:072312Death Benefit Claim Request 401(k) Plan Refer to the Death Benefit Claim Guide while completing this form.
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