Transcription of Tier One/Tier Two/Individual Account Program (IAP ...
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Tier One/Tier Two/Individual Account Program (IAP ...
Form #459-364 (8/10/2017) SL3 IIM Code: 2163 Page 1 of 6 Section A: Applicant information11410 SW 68th Parkway, Tigard OR 97223 Mailing Address PO Box 23700, Tigard OR 97281-3700 Toll free 888-320-7377 fax 503-598-0561 Website C: Spousal consent and notarized signatureSection B: Retirement options (Select a survivorship or a non-survivorship option.) Survivorship Options (Name a benefi ciary.) Non-Survivorship Options Option 2 Option 3 Lump-Sum Option 2 Lump-Sum Option 3 Option 1 Refund Annuity 15-Year Certain Lump-Sum Option 1 Total Lump-Sum Option 2A Option 3A Lump-Sum Option 2A Lump-Sum Option 3 ABenefi ciary nameBenefi ciary Social Security numberBenefi ciary date of birth (mm/dd/yyyy)Relationship to youTier One/Tier Two/Individu
Form #459-364 (8/10/2017) SL3 IIM Code: 2163 Page 3 of 6 First name MI Last name Social Security number Section I: Tier One/Tier Two lump-sum distribution installments
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