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)

• Payments made under a qualified domestic relations order (QDRO) • Payments up to the amount of your deductible medical expenses • Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more than 179 days

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  Form, Distribution, Domestic, Request, Order, Qualified, Relations, Distribution request form, Qualified domestic relations order, Qdro

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