Step 1 of 3: Supply Information | Step 2 of 3: Confirm Entries | Step 3 of 3: Submission Confirmation
Please Note: This form version MUST be completed online.
For a downloadable version to submit via mail or fax, please click here
IMPORTANT NOTICE: Before You Sign, Read All Information on this form:
- Please supply the information requested below.
- Read all agreements on this form before submitting.
- Fields having an asterisk notation are required.
Further information regarding IRS regulations relating to this subject can be found at the IRS website
or in the 2009 IRS Publication 571
403(b) Plan Sponsor:
Please provide the information for the employer from whose plan you wish to withdraw funds.