When an individual decides to request a one-time cash distribution from their employer-sponsored retirement plan, such as a 401(a), 401(k), 403(b), or 457(b) plan, the Payout Form becomes an essential document. This form, designed to facilitate cash distributions, requires the individual to fill it out with detailed personal and plan information using CAPITAL letters and black ink or through an electronic file if available. Notably, the form accommodates various situations, including distributions for former employees who have separated from service and current employees who qualify by age, among other reasons. It is crucial for individuals to understand that taking a distribution might have tax implications, and consulting with a tax or financial professional could be beneficial. Furthermore, the form outlines options for distribution amounts, tax withholding preferences, and delivery methods, ensuring that recipients can tailor the distribution to their needs. For married individuals, spouse's consent is necessary under certain conditions, emphasizing the importance of understanding the requirements specified in one's retirement plan. The form also stresses the need for accuracy and completeness, including possible requirements for a signature guarantee or notarization in specific scenarios, to ensure the prompt and correct processing of the distribution request.
| Question | Answer |
|---|---|
| Form Name | Payout Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | mmbc online payout form, pay out form, aviva payout form, payout request form |
Questions? Call
Distribution — Cash
Use this form to request a
Helpful To Know
•You can only take a distribution if you meet one of the criteria for eligibility (see Section 3). If you are a benefi- ciary or qualified alternate payee, call Fidelity instead of using this form.
•Workplace retirement plan distributions may have tax consequences. You may want to consult a tax or finan- cial professional.
•To get your plan number(s), call your plan sponsor or go to fidelity.com/atwork.
•To validate your profile, go to netbenefits.com/profile. To change your address, call your plan sponsor or go to netbenefits.com/profile.
•For most other types of distributions (such as automatic,
hardship, or rollover) find the appropriate forms at fidelity. com/atwork.
•
1. Account Owner / Participant
Name
Social Security or Taxpayer ID Number
Date of Birth MM – DD – YYYY
Evening Phone
Daytime Phone
Not married
Married Your spouse may need to sign this form. Ask your employer or Fidelity.
ADDRESS If the address we have for you is correct, skip to Section 2.
Providing a new address may delay your check unless you get a signature guar- antee (see Section 8).
Address
City
State/Province
Zip/Postal Code
Country
2. Plan(s) Involved The distribution you request in Section 4 will apply to EACH PLAN listed here.
To get your plan number(s), go to netbenefits.com/ profile or call the employer sponsor- ing your plan(s).
Plan Type(s) and Number(s) List ONLY plans sponsored by the employer named below.
401(a) |
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401(k) |
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403(b) |
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457(b) |
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Plan Number |
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Plan Number |
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Plan Number |
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Plan Number |
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To request distribu- tions from different employers, submit separate forms.
Name of Employer Sponsoring Plan(s)
3. Reason for Distribution Required by federal tax law and your plan.
Check ONLY one.
Contact the employer sponsoring your plan(s) to confirm which reasons your plan(s) accepts and whether you qualify.
Former Employees
Separation from service You no longer work for the employer sponsoring the plan.
Disability Varies depending on several factors; you will need to provide documentation to your employer. Current Employees
Qualified by age Age requirement varies by plan type. You must be at least 59½ (for 457(b), 70½).
Other Must be specified in your plan.
Disability Varies depending on several factors; you will need to provide documentation to your employer.
3.TEMDISTCW.100 |
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026360001 |
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4. Distribution Amount Your available plan assets may be less than your plan value. Tax withholding may apply.
Choose ONLY one of the four distribution types and provide any required information.
These instructions will be applied to EACH plan you listed in Section 3. For example, if you listed two plans and request a $5,000 distribution, we will withdraw $5,000 from the first plan and
$5,000 from the second.
You may check more than one source type (for example,
ALL available plan assets
ONLY this amount, drawn proportionally from all available plan assets:
Amount
$
ONLY this type(s) and percentage of available plan assets:
100% |
100% |
100% Roth |
ONLY the following amounts drawn from this type(s) of available plan assets:
Roth |
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Amount |
Fund Name or Number |
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$ |
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Roth |
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Amount |
Fund Name or Number |
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$ |
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Roth |
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Amount |
Fund Name or Number |
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$ |
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5. Tax Withholding
The IRS requires us to apply withholding on any taxable distribution (including any distribution that is eligible for rollover, but is not rolled over). Each state sets its own withholding rates and requirements on taxable distributions. We apply these rates unless you, or state law, direct otherwise.
Note that the amount of tax withheld will be calculated on, and subtracted from, the amount of your distribution. Amounts withheld may be less or more than what you actually owe in taxes. To review the Special Tax Notice for details, go to fidelity.com/atwork.
For U.S. Persons the minimum federal mandatory withholding rate of 20% will apply. For
You can indicate a higher withholding rate if you choose, but if you indicate no rate, or a rate below an applicable federal minimum, by law we must withhold the applicable minimum. If you are under age 59½, a 10% early distribution tax penalty may apply.
Account’s legal / residential address determines which state’s tax rules apply.
Federal
Withhold federal taxes at the rate of:
Percentage |
Note that if there is federal withholding, |
.0% |
certain states require that there also be |
state withholding. |
State
Withhold state taxes at the applicable rate
Do NOT withhold state taxes unless required by law
6. Delivery Method Transaction timings start from when your distribution request is approved, and are estimates, not guarantees.
Choose ONLY one delivery method and provide any required information.
Ask your bank for the routing number.
This option not available for PO Box or foreign addresses.
Electronic Funds Transfer (EFT) At least one owner’s name must be exactly the same on both accounts.
EFT is already set up on account Allow 3 business days. Skip to Section 7.
Set up EFT to bank or credit union account:
Allow
Checking Provide account information or attach voided check. |
Savings Provide deposit slip. |
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Bank Routing Number Nine digit number starting with 0, 1, 2, 3, or 4. |
Bank Name |
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Bank Account Number |
Bank Account Owner(s) Name(s) |
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Check
Check sent to mailing address Default if no choice indicated. Allow 7 business days.
Check sent by UPS delivery A fee of $25 will be deducted from your account. Allow 2 business days. Deposit Allow 3 business days.
Deposit into Fidelity
Account Number
3.TEMDISTCW.100 |
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026360002 |
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7. Spouse’s Consent Complete if you are married AND if required by your plan.
The spouse’s signature MUST either be notarized or be witnessed by a plan representative. A signature guarantee is NOT a notary seal. By signing below, you:
•Voluntarily consent to the distribution(s) indicated on this form, knowing that your spouse’s request is not valid without your consent.
•Acknowledge that you may be giving up your right to receive assets that would otherwise go to you upon your spouse’s death.
•Acknowledge that your spouse’s waiver of a qualified joint and survivor annuity, if applicable, is not valid without your consent.
•Agree that if the distribution described in this form is not processed within 180 days of the date you sign this form, your consent expires.
•Acknowledge that you cannot take back your consent unless your spouse allows you to, and files a new form with Fidelity.
Print Spouse Name
Spouse Signature |
Date MM – DD – YYYY |
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S I G N |
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Notarization or Plan Representative Witness
(Notary only.) State of |
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, in the County of |
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, subscribed and sworn to before me by |
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the |
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as identification, that the |
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foregoing statements were true and accurate and made of his/her own free act and deed, on |
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Print Notary / Plan Representative Name
NOTARY SEAL / STAMP
Notary / Plan Representative Signature |
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Date MM – DD – YYYY |
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S I G N |
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(Notary only.) My commission ends on |
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8.Signature and Date Account owner / participant must sign and date.
If the retirement plan requires a signature from the plan sponsor in Section 10, you do not need a signature guarantee. If the retirement plan does NOT require a plan sponsor signature, you will need a signature guarantee if either of two cases applies:
•Your distribution is more than $10,000 and is not going to a Fidelity account, you are providing a new address, AND it’s important that your transaction not be delayed by 15 days.
•Your distribution is more than $100,000.
A Medallion signature guarantee must guarantee at least the amount of your distribution. A notary seal is NOT a signature guarantee.
By signing below, you:
•Authorize Fidelity to act on all instructions given on this form.
•Accept all terms and conditions described in this form.
•Certify that all information you provided is correct to the best of your knowledge.
•Acknowledge that you have received the Special Tax Notice and, if applicable, the Forms of Benefit Notice and the Notice of the Waiver of the Qualified Joint and Survivor Annuity.
Medallion Level Fidelity Use Only
Print Participant Name
Date MM – DD – YYYY
EAT
D
Participant Signature
NG
IS
The signature guarantee above is NOT a Medallion signature guarantee:
SIGNATURE GUARANTEE
Financial Institution Representative Name
Phone
Extension
3.TEMDISTCW.100 |
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026360003 |
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9. Plan Sponsor Approval
Consult the employer sponsoring your plan or Fidelity to determine whether plan sponsor approval is required. You may need plan sponsor approval even if you no longer work for the sponsor.
Participant’s Date of Hire MM – DD – YYYY
Separation Date If applicable MM – DD – YYYY
%
By signing below, you:
•Acknowledge that the distribution as requested on this form is permitted by the employer’s plan.
•Certify that you are on record with Fidelity as being authorized to sign on behalf of the plan sponsor.
Print Plan Representative Name
Plan Representative Signature |
Date MM – DD – YYYY |
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S I G N |
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Did you print and sign the form, and attach any necessary documents? Did ALL required individuals sign? Send the form and any necessary documents to Fidelity.
Faxing
Questions? Go to fidelity.com/atwork or call
Unless otherwise directed, deliver to:
Regular mail |
Overnight mail |
Fidelity Investments |
Fidelity Investments |
PO Box 770002 |
100 Crosby Parkway KC1E |
Cincinnati, OH |
Covington, KY 41015 |
On this form, “Fidelity” means Fidelity Investments Institutional Operations Company, Inc.
3.TEMDISTCW.100 584358.1.0 |
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026360004 |
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