Transcription of DISTRIBUTION REQUEST FORM - T. Rowe Price
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DISTRIBUTION REQUEST FORM - T. Rowe Price
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
2015-AX-6759 2/15 OIM11-DISA. ... as taxable income as appropriate. The address on this form will determine my state of residence for state withholding purposes. I also understand that the distribution will be subject to income taxes unless I ... If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions
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