Nationwide Distribution Request
Participant
Distribution Request
CASE NUMBER: _________________
?
Nationwide Retirement Plans ? Phone: 1©\877©\588©\6724 ? Fax: 1©\877©\NF401ks (1©\877©\634©\0157)
Purpose of Form
This form is to be used for participant/beneficiary level withdrawal types listed below in Section 2, if
available in your plan. Financial hardship requests are submitted on a specific Financial Hardship
withdrawal form. This form is to be used for participants of plans where Nationwide serves as third
party administrator.
Case Information
_
Case Number
Section 1
Participant
Information
Case Name
_
Participant Name
Social Security Number (###©\##©\####)
Date of Birth (MM/DD/YYYY)
Date of Hire (MM/DD/YYYY)
Home Address
City
State
ZIP Code
Telephone Number
Marital Status:
Section 2
Reason for
Distribution
Single
Married
Divorced
Widowed
Check the option that applies:
Termination of Employment*
Withdrawal of Rollover Contributions**
Attainment of Normal Retirement Age
Withdrawal of After©\Tax Voluntary Contributions**
Plan Termination
In©\Service Withdrawal**
Total and Permanent Disability
Reservist Called to Active Military Service Distribution
Death (for beneficiaries only ©\ attach a certified copy of the death certificate)
* Transferring from one employer to another within the same controlled group does not
constitute termination of employment and is not a distributable event.
** If permitted under the terms of the Plan Document
PNN©\1015AO.7
Page 1 of 15
(PAGES 1©\7 MUST BE RETURNED)
08/2014
CASE NUMBER:
Section 3
Cash Distribution
Cash Payment ©\This will be a taxable distribution (with the possible exception of Roth or after©\tax
contributions) and taxes will be withheld as required by law. Additional Federal or State
withholding can be requested in Section 7.
Total distribution of vested account balance(s).
Partial distribution (if allowed) of my vested account balance(s) in the amount of:
$
_
GROSS (before taxes)
OR
NET (after taxes)
Combination of Cash Payment and Direct Rollover ©\ Any portion of this payout that is paid directly
to me will be a taxable distribution (with the possible exception of Roth or after©\tax contributions)
and taxes will be withheld as required by law. Additional Federal or State withholding can be
requested in Section 7.
I request a cash payment of $
.
GROSS (before taxes)
OR
NET (after taxes)
(With the remaining vested balance being directly rolled over per the rollover instructions).
Cash Payment Method:
Send check by first class mail.
ACCOUNT NOTE:
If checking or savings
is not chosen, we will
default to checking. If
any information is
missing or incorrect a
check will be issued.
Send check overnight by UPS. I understand that standard processing time still applies and there is
an additional $25 fee for the UPS overnight shipping charges that will be deducted from my account.
Direct Deposit by ACH.
Type of Account:
Checking
OR
Savings Account
_
Bank Name
_
City, State, and Zip Code
_
ABANumber
_
Account Number
_
Name on Account
PNN©\1015AO.7
Page 2 of 15
(PAGES 1©\7 MUST BE RETURNED)
08/2014
CASE NUMBER:
Section 4
Direct Rollover
Distribution
Direction
Direct Rollover ¨C A check will be sent directly to the custodian/trustee indicated below. Be sure
your plan/IRA allows rollovers from these sources.
Please choose the appropriate direct rollover option(s) below:
Rollover of Pre©\tax vested balance to a Traditional IRA
Rollover of Pre©\tax vested balance to another eligible retirement plan.
WIRE and ACH NOTE:
Wires and ACH are not
available payment
options for rollovers.
Rollover of Pre©\tax vested balance to a ROTH IRA ¨CThere is no tax free treatment for a
distribution rolled over to a Roth IRA. This distribution will be reported as taxable
income for the year distributed. Nationwide will not withhold Federal or State taxes
unless specifically requested in Section 6.
Please choose the appropriate direct rollover option(s) below if you have ROTH contributions:
Rollover of ROTH 401(k)/403(b) account balance to a ROTH IRA.
Rollover of ROTH deferrals to another 401(k), 403(b) or governmental 457 plan¡¯s ROTH
elective deferral account
This direct rollover is for (please check one):
Total Vested Balance
OR
Specific Amount $
Account Information:
ROTH ACCOUNT
NOTE: When both
ROTH and pre©\tax
funds are being rolled
over, separate account
numbers must be
provided.
Check Payable to Trustee/Custodian
_
Traditional (Pre©\Tax) Account Number
ROTH Account (if applicable)
Address of Trustee/Custodian
City
State
Zip Code
Payment Method:
Send check by first class mail.
Send check overnight by UPS. I understand that standard processing time still applies and
there is an additional $25 fee for the UPS overnight shipping charges which will be
deducted from my account.
PNN©\1015AO.7
Page 3 of 15
(PAGES 1©\7 MUST BE RETURNED)
08/2014
CASE NUMBER:
Section 5
Annuity
Purchase
This option is not available to all plans. To verify available options under your plan, please contact the
plan sponsor.
Life annuity with
60,
Annuity for life, with
120, or
50%,
240 monthly payments guaranteed.
66 2/3 %,
75%, or
100% survivor annuity.
Upon my death paid to:
Name of Joint Annuitant
Joint Annuitant Date of Birth (MM/DD/YYYY)
Annuity with payments over
_ years.
Other:
Section 6
Federal and
State Tax
Withholding
Note: Do not complete this section if this is a rollover to another eligible retirement plan or IRA.
If your benefit is paid directly to you and is an eligible rollover distribution, please note that a mandatory
20% Federal withholding and any mandatory state withholding will apply to the taxable portion of your
distribution prior to receiving the funds.
Federal Taxes:
Please select one of the options below, only if you are not requesting a rollover to another eligible retirement
plan or IRA.
Please withhold only the mandatory Federal tax rate from my distribution (20%).
Note: This will be the default if no option is selected.
OR
I wish to withhold an amount greater than the mandatory 20% Federal tax rate from my distribution.
Note: The amount designated below must be greater than 20%
_% or
$
State Taxes:
Indicate below the state taxes to be withheld from your distribution.
Note: If you reside in a state that requires mandatory taxes, the applicable tax rate will be
withheld even if you enter a lesser amount or leave this section blank. Otherwise, we will
withhold taxes as directed below.
____________% or ____________$ for the State of _____________________
Note: If you do not have enough taxes withheld, you may be responsible for payments of estimated
income tax and penalties. For further details, see the attached Special Tax Notice regarding Plan
Payments.
PNN©\1015AO.7
Page 4 of 15
(PAGES 1©\7 MUST BE RETURNED)
08/2014
CASE NUMBER:
Section 7
Beneficiary
Information for
Death Benefits
NOTE: If there are
multiple beneficiaries
then each beneficiary
must complete a
separate form.
Section 8
Participant/
Beneficiary
Authorization
_____________________________________________________________________
Type or Print Payee Full Name
Payee Social Security Number
_____________________________________________________________________
Payee Home Address (number and street or rural route)
Phone Number
_____________________________________________________________________
City, State and Zip Code
_____________________________
Payee Date of Birth (MM/DD/YYYY)
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for
a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I
have not been notified by the Internal Revenue Service (IRS) that I am subject to backup
withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me
that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person.
By signing below, I hereby acknowledge the following information:
1. Rollover contributions to governmental 457(b) plans that originated from qualified plans, IRAs
and 403(b) plans are subject to the early distribution tax that applies to 401 plans unless an
exception applicable to 401 plans applies.
2. Rollover contributions are subject to the Required Minimum Distribution (RMD) rules of the plan
they are rolled into, not the plan or IRA from which they came.
Federal income tax will be withheld from your payments as required by the Internal Revenue Code. If
you select a lump sum or systematic withdrawal lasting less than 10 years 20% of the taxable portion of
the distribution paid to you will be withheld for federal income taxes. State taxes will be withheld
where applicable. State and federal taxes withheld will be reported on a form 1099©\R.
The Internal Revenue Service does not require your consent to any provision of this document other
than the certifications required to avoid backup withholding.
I consent to a distribution as elected above. I understand that the terms of the plan document will
control the amount and timing of any payment from the plan. Further, I certify that I have read and
received the attached Special Tax Notice Regarding Plan Payments. If I elect to receive this distribution
before the end of the 30 day minimum notice period, my signature on this election form shall constitute
a waiver of my rights to the 30 day notice requirement, if applicable.
I hereby authorize the above elected benefit and attest to the accuracy of the information.
I acknowledge that a withdrawal fee may apply and will be deducted from my account.*
Also, I understand that once submitted this election is final.
Participant/Beneficiary Signature
Dated (MM/DD/YYYY)
*The amount of the fee is stipulated in the service agreement for the plan and may be obtained from
your employer.
PNN©\1015AO.7
Page 5 of 15
(PAGES 1©\7 MUST BE RETURNED)
08/2014
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.