Transcription of Plan Information Participant Information
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Example: bachelor of science
Plan Information Participant Information
Products and financial services provided byAmerican United Life Insurance Company a OneAmerica companyOne American Square, Box 6011 Indianapolis, IN 46206-60111-800-249-6269In-Service Distribution RequestPage 1 of 4R-19305 1/27/14 plan InformationPlan Number Division (if applicable) plan NameParticipant Information First Name Last Name M FSocial Security (or Taxpayer ID) Number Sex Date of BirthStreet AddressStreet Address City StateZip CodeWork PersonalTelephone Number (including area code) E-mail AddressDistribution Information Full Withdrawal Check this box to request distribution of your entire vested account balance, less any applicable tax withholdingand/or fees.
Page 2 of 4 R-19305 1/27/14 Distribution Information (continued) Tax Withholding Federal Tax Withholding –The Internal Revenue Service requires income tax withholding of 10% for hardship distributions unless you elect otherwise. All other benefit distributions require 20% income tax withholding unless
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