Doe 403B Form – Fill Out and Use This PDF

Participant

The State of Hawaii DOE 403(b) Distribution/Rollover Authorization Form must be submitted to National Benefit Services, LLC (NBS), the third party administrator, to

Instructions

authorize a distribution or rollover of 403(b) amounts from your employer or former employer's plan. Two types of distributions do not require this form. 1) Hardship

distributions require submission of a different form, the State of Hawaii DOE 403(b) Hardship Authorization Form. 2) Required minimum distributions following attainment

of age 70 1/2 do not require NBS authorization. Your investment provider may require its own paperwork in addition to this form. You may wish to attach your

investment provider's paperwork to this form. All attached forms or paperwork will be forwarded to the investment provider indicated below. Complete steps 1-4 and

mail or fax this form to NBS. Inquiries regarding the status of your distribution or rollover may be directed to NBS at (800) 274-0503 ext 5. After paperwork has been

forwarded to your investment provider, inquiries should be directed to your provider. After this form has been received by NBS in good order, it will be forwarded to your

provider within 5 business days. Submission of this form does not affect any existing salary reduction arrangements you currently maintain with the DOE. If you wish to

discontinue or direct future contributions to a new vendor you must complete a corresponding new salary reduction agreement (SRA). An SRA form can be found at the

website www.hawaiidoe403b.com.

NBS Mailing Address:

National Benefit Services, LLC

NBS Fax Number:

800-597-8206

8523 South Redwood Road

NBS Email - for questions only:

403bservice@nbsbenefits.com

West Jordan, UT 84088

NBS Phone Number:

800-274-0503 ext. 5

Investment

NBS represents this participant (or beneficiary) is eligible to distribute or rollover 403(b) amounts in accordance with the employer's plan and the 403(b)

Provider

Provider/Information Sharing Agreement (Agreement) entered into by your company and NBS, provided that NBS has signed below. NBS reserves the right to not sign

Instructions

surrendering or receiving vendor paperwork according to the ISA (if applicable).

Step 1

Participant Name

Social Security Number

Date of Birth

Participant

Participant Mailing Address

Home Phone Number

Work Phone Number

Information

(Street)

Agent Name

Agent Phone Number

(City, ST ZIP)

Current or former place of employment (School Name)

Step 2

Select all applicable reasons for withdrawal and the date of the applicable event. If none of the events listed below apply to you, you may not be eligible for a distribution

or rollover. You may still be eligible to transfer 403(b) amounts to a different investment provider using the State of Hawaii DOE 403(b) Exchange Authorization Form.

Reason(s)

Contact your investment provider, financial advisor, or NBS for additional information. Note that QDROs may require additional processing time. Retirement is considered

termination of employment if you are no longer working for the sponsoring employer - The State of Hawaii DOE.

for

Withdrawal

Distributable Event:

Termination of employment (no longer working for the Sponsoring Employer)

Date of event :

Attainment of age 59 ½

Required minimum?

Y

N

Date of event :

Death of participant (provide documentation)

Date of event :

Disability (must be long-term and result in inability to work; provide documentation)

Date of event :

QDRO (provide documentation)

Date of event :

Correction of excess contribution or deferral

Tax year :

Step 3

Indicate the investment provider that currently holds the assets you wish to distribute or rollover. This form will be sent to the investment provider below unless instructed

otherwise.

Source of

Investment Provider:

Assets

Account Number

Street or P.O. Box

City, State, Zip

Phone Number

Fax Number

Step 4

I recognize that the information contained on and attached to this form may be shared with a third party (including National Benefit Services, LLC (NBS)) as necessary to

administer the Plan in accordance with the Internal Revenue Code. I authorize the release of non-public information pertaining to the above accounts and transaction to

Participant/

NBS representatives as necessary to administer the plan. I certify that the information I have provided is accurate. I understand that taxes and tax withholding may apply

to any distribution I receive that is not rolled over. Additionally, a 10% IRS penalty may be assessed for early distributions. Consult with a tax advisor for tax-related

Beneficiary

questions.

Approval

Participant Signature (or Beneficiary Signature if participant is deceased) (Required)

Date

For NBS

Use Only

Ver: 6-2010

NBS Signature (Required)

Date