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)

• The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse).

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

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