Nationwide Retirement Solutions Participant Distribution Request Form (PNF-0875M9, TRAC Version, 01/2025) Instructions

Check this box to authorize the payment of retirement plan benefits as requested by the participant and to attest to the accuracy of the contained information.

Check this box to authorize the payment of retirement plan benefits as a single sum payment under the Plan's Cash Out provisions, applicable if allowed by the Plan, vested benefits do not exceed $1,000, and participant/spousal consent is not required.

Check this box to authorize the payment of retirement plan benefits as an automatic rollover to an established IRA under the Plan's Cash Out provisions, applicable if allowed by the Plan, vested benefits are less than $5,000, and participant/spousal consent is not required.

Provide the requested amount for the cash payment.

Check this box if the cash payment should be a gross distribution (amount before taxes).

Check this box if the cash payment should be a net distribution (amount after taxes).

Check this box if you want your cash payment sent by first class mail to your address of record. This is the default payment method if no other option is selected.

Check this box if you want your cash payment to be sent via Direct Deposit (ACH) to the account you indicate below.

Check this box if you wish to be contacted via the telephone number of record.

Check this box if you wish to be contacted via US mail.

Provide the name of the financial institution for direct deposit.

Provide the nine-digit ABA routing number of the financial institution.

Provide the bank account number for direct deposit.

Check this box if the direct deposit funds should be sent to a savings account.

Check this box if you want the direct rollover distribution check sent to the Trustee/Custodian at the address indicated in the Rollover Account Information Section.

Check this box if you want the direct rollover distribution check sent to your address of record.

Check this box if you elect to opt-out of federal income tax withholding, resulting in 0% withholding.

Check this box if you wish to have a different percentage of federal income tax withheld and will submit the required Form W-4P or W-4R.

Check this box if you wish to have additional federal income taxes withheld for payments lasting less than 10 years, and are submitting the Form W-4R.

Enter the printed full name of the notary.

Enter the date the document was notarized.

Enter the date the notary's commission expires.

Check this box if you want a partial cash distribution (if allowed by the Plan) from your vested account balance and will specify the amount.

Enter the amount of the partial cash payment distribution from the vested account balance.

Check this box if you want the gross distribution amount (before taxes) for your cash payment. This is the default method if no other option is selected.

Check this box if you want the net distribution amount (after taxes) for your cash payment.

Check this box if you wish to make a partial direct rollover distribution, provided it is allowed by your plan, for a specific amount of your vested account balance.

Enter the amount of the partial direct rollover distribution from your vested account balance.

Check this box if the participant was an officer of the company.

Check this box if the participant was an owner of the company.

Enter the participant's percentage of ownership in the company.

Enter the full name of the participant.

Enter the Social Security Number of the participant.

Enter the participant's date of birth.

Enter the participant's date of hire.

Enter the participant's phone number.

Enter the participant's street address.

Enter the city of the participant's address.

Enter the state of the participant's address.

Enter the zip code of the participant's address.

Check this box if the participant's marital status is single.

Enter the participant's email address for paperless communication.

Enter the date the participant signed the form.

Enter the participant's termination date.

Enter the date of the participant's final payroll deduction.

Provide the total number of hours worked by the participant in the current year.

Provide the total number of hours worked by the participant in the prior year.

Enter the identification number for the plan.

Enter the full name of the plan.

Check this box if the plan type is 401(k).

Check this box if the plan type is 403(b).

Check this box if the plan type is 457(b).

Check this box if the plan type is 401(a) Profit Sharing.

Check this box if the plan type is 401(a) Money Purchase.

Enter the printed name of the Plan Sponsor or Designated Plan Administrator (DPA).

Enter the date the Plan Sponsor or Designated Plan Administrator (DPA) signed.

Select this option if you have no pre-tax contributions for which to choose a rollover option.

Select this option to roll over your pre-tax vested balance into a Traditional IRA.

Select this option to roll over your pre-tax vested balance into another eligible retirement plan.

Select this option to roll over your pre-tax vested balance into a Roth IRA, acknowledging this distribution will be taxable and taxes will not be withheld unless specifically requested.

Check this box if the distribution is due to the termination of your employment.

Check this box if the distribution is a withdrawal of rollover contributions.

Check this box if the distribution is due to the termination of the plan initiated by the employer.

Check this box if the distribution is for a reservist called to active military service.

Check this box if the distribution is a withdrawal of after-tax voluntary contributions.

Select this option if repetitive cash payments should be made on a monthly basis.

Select this option if repetitive cash payments should be made on a quarterly basis.

Select this option if repetitive cash payments should be made on a semi-annual basis.

Select this option if repetitive cash payments should be made on an annual basis.

Enter the date when the repetitive cash payments should begin.

Enter the gross amount of the repetitive cash payment.

Provide the name of the trustee or custodian to whom the check should be made payable.

Enter the account number for the pre-tax funds rollover.

Enter the account number for the Roth funds rollover.

Provide the full street address of the trustee or custodian.

Enter the city of the trustee or custodian's address.

Enter the state of the trustee or custodian's address.

Enter the zip code of the trustee or custodian's address.

Check this box if there are no Roth contributions to roll over.

Check this box to roll over the Roth account balance to a Roth IRA.

Check this box to roll over the Roth account balance to another 401(k), 403(b), or governmental 457(b) plan's Roth Rollover account.

Check this box if you certify you are not married and/or the plan does not require spousal consent.

Enter the printed full name of the spouse.

Enter the date the spousal consent was signed.

Enter the state where the spousal consent was witnessed by the notary.

Enter the country where the spousal consent was witnessed by the notary.

Provide the identification details that the individual produced to the notary.

Enter the date when the deed was made.

Check this box if you want to receive your entire vested account balance as a cash payment.

Check this box if you wish to directly roll over your entire vested account balance.

Enter the date the Plan Sponsor witnessed the signature.