Form 403(B)(7) - Erisa Retirement Plan Template
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1
2Vanguard Plan #
0
(Plan Name)
Distribution Request
403(b)(7) ERISA Retirement Plan
(Retirement / Severance from Employment / Disability)
Please call 1-800-523-1188 with any questions regarding this form.
Direct Rollover
1. Account Information
Date of birth
Social Security #
(mm/dd/yyyy)
Name
(Last, First, MI)
Address
City
State
Zip
Daytime Phone #
Check here if address listed above is a new address.
2. Withdrawal Method
Reason for Distribution:
Severance from employment
Disability
Retirement
Form of Distribution: (choose one)
Note: These options apply to either a partial or total direct rollover. See reverse side of this form for additional information.
Lump Sum Cash
Installments
Partial Distribution
Specific Fund(s) ___________ or Prorated
Skip to Section 3
(Complete Installment
Dollar Amount: $__________ or Percentage: __________ %
Payment Request Form)
Direct Rollover to Vanguard traditional IRA
Direct Rollover to Other Eligible Retirement Plan or Non-Vanguard IRA
(Complete this form and a Vanguard IRA
(Complete this form and obtain further instructions from the receiving institution.)
Adoption Agreement)
Note: Additional forms of distribution may be available. Please contact your Benefits office.
2a. Direct Rollover Information
You may roll over any or all of your distribution.
% To be transferred as direct rollover
%
Pre-Tax:
% To be paid to me
%
100%
Check One:
Traditional IRA
Eligible Employer Plan
(See the Special Tax Notice for the defiinition of eligible employer plan)
Trustee/Custodian
Name
(Please show name exactly as check should be made out)
Account Number
Note: If account number is not provided, the Direct Rollover check will be mailed to you.
Mail check to me
Mail check to institution at the address below.
City
State
Zip
% To be transferred as direct rollover
%
After-Tax:
% To be paid to me
%
100%
Note: After-tax 403(b)(7) assets can only be rolled over into a traditional IRA or another 403(b) plan, subject to the
receiving plan's provisions.
Check One:
Traditional IRA
403(b)
Trustee/Custodian
Name
(Please show name exactly as check should be made out)
Account Number
Note: If account number is not provided, the Direct Rollover check will be mailed to you.
Mail check to me
Mail check to institution at the address below.
City
State
Zip
Complete reverse side.
T20944_022003
(2/11/2003)
Term403E
Please make a copy for your records.
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