DISTRIBUTION REQUEST FORM

DISTRIBUTION REQUEST form If you wish to take a DISTRIBUTION or roll over your account to another retirement account , please complete: 1. Participant Information 2. Type of DISTRIBUTION 3. Method of disbursement 4. Participant Authorization 5. plan Administrator Authorization and Vesting Verification Fax the completed form to 816-218-0424. PARTICIPANT INFORMATION plan Name _____ plan ID_____ First Name and Middle Initial _____ Last Name _____ Social Security Number _____ Daytime Phone Number_____ Evening Phone Number _____ Address _____ City _____ State _____ ZIP_____ TYPE OF DISTRIBUTION Termination of Employment Date _____/_____/_____ retirement Date _____/_____/_____ Disability Date _____/_____/_____ (Disability as determined by the plan administrator on the basis of written determination by the Social Security Administration that disability payments under the Social Security Act have been approved)

If you wish to take a distribution or roll over your account to another retirement account, please complete: 1. Participant Information 2. Type of Distribution 3. Method of Disbursement 4. Participant Authorization 5. Plan Administrator Authorization and Vesting Verification Fax the completed form to 816-218-0424. PARTICIPANT INFORMATION

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  Form, Distribution, Account, Plan, Request, Retirement, Disbursement, Distribution request form, Retirement account

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