PARTICIPANT DISTRIBUTION 1099-R INFORMATION REQUEST
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__________________________________________________________________________
REQUEST TO CALCULATE BENEFITS
PLAN NAME ______________________________
Please calculate benefit payments for the following terminated participant(s):
Name: ______________________________________________________________
Address:____________________________________________________________
City, State, Zip:_______________________________________________________
Date of Termination:_________________ Social Security #____________________
Year to date salary__________________ Year to date hours __________________
If Participant is married:
Spouse’s Name______________________________ Date of Birth______________
Name: ______________________________________________________________
Address:____________________________________________________________
City, State, Zip:_______________________________________________________
Date of Termination:_________________ Social Security #____________________
Year to date salary__________________ Year to date hours __________________
If Participant is married:
Spouse’s Name______________________________ Date of Birth______________
Name: ______________________________________________________________
Address:____________________________________________________________
City, State, Zip:_______________________________________________________
Date of Termination:_________________ Social Security #____________________
Year to date salary__________________ Year to date hours __________________
If Participant is married:
Spouse’s Name______________________________ Date of Birth______________
_________________________________________________ Date _____________
Plan Administrator/Employer
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