This form contains 101 fields organized into 14 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Cash Payment Distribution Options
Total distribution of vested account balance	Checkbox	Check this box to receive the entire vested account balance as a cash payment (full distribution).
Partial distribution of vested account balance	Checkbox	Check this box to receive a partial cash distribution of your vested account balance and enter the dollar amount on the provided line.
Partial Distribution Amount	Number	Enter the dollar amount you are requesting as a partial cash distribution of your vested account balance. Fill only if 'Partial distribution of vested account balance' is 'Yes'. Depends on: Partial distribution of vested account balance
Gross distribution (amount before taxes)	Checkbox	Check this box to receive a gross cash distribution (amount before taxes are withheld); this is the default method if no option is selected.
Net distribution (amount after taxes)	Checkbox	Check this box to receive a net cash distribution after required taxes have been withheld.
Cash Payment Method - Mail Check Option
Send check by first class mail to my address of record	Checkbox	Check this box when you want the cash payment mailed by first-class mail to your address of record (default method if no other option is selected); allow 5–10 business days from the process date for delivery.
Cash Payment Type (Gross or Net)
Gross distribution (amount before taxes)	Checkbox	Check this box when you want the cash payment paid as a gross distribution (amount before taxes are withheld).
Net distribution (amount after taxes)	Checkbox	Check this box when you want the cash payment paid as a net distribution (amount after taxes have been withheld).
Direct Deposit ACH Financial Institution Information
Direct Deposit Financial Institution Name	Text	Enter the full name of the bank or financial institution where you want the ACH deposit sent. Fill only if 'Direct Deposit ACH' is 'Yes'. Depends on: Direct Deposit ACH
Direct Deposit ABA (Routing) Number	Number	Enter the bank routing (ABA) number associated with the financial institution for the ACH transfer. Fill only if 'Direct Deposit ACH' is 'Yes'. Depends on: Direct Deposit ACH
Direct Deposit Account Number	Number	Enter the account number at the financial institution where the funds should be deposited. Fill only if 'Direct Deposit ACH' is 'Yes'. Depends on: Direct Deposit ACH
Account Type - Checking	Checkbox	Check this box when the account you are providing for Direct Deposit ACH is a checking account. Fill only if 'Direct Deposit ACH' is 'Yes'. Depends on: Direct Deposit ACH
Account Type - Savings	Checkbox	Check this box when the account you are providing for Direct Deposit ACH is a savings account. Fill only if 'Direct Deposit ACH' is 'Yes'. Depends on: Direct Deposit ACH
Direct Deposit ACH	Checkbox	Check this box when you want your distribution sent via ACH direct deposit to the bank account you provide on this form.
Direct Rollover Options
Total Direct Rollover Distribution of my vested account balance	Checkbox	Check this box when you want the entire vested balance in your account to be sent as a direct rollover to another eligible retirement account.
Partial Direct Rollover Distribution (if allowed) of my vested account balance in the amount of	Checkbox	Check this box when you want only a portion of your vested balance rolled over directly to another eligible retirement account and you will specify the dollar amount on the form.
Direct Rollover — Partial Distribution Amount	Number	Enter the dollar amount of your vested account balance to be directly rolled over to another plan or IRA. Fill only if 'Partial Direct Rollover Distribution (if allowed) of my vested account balance in the amount of' is 'Yes'. Depends on: Partial Direct Rollover Distribution (if allowed) of my vested account balance in the amount of
General
Requested cash payment amount	Number	Enter the dollar amount you are requesting as the cash payment to be paid now, with the remaining balance to be directly rolled over.
Check Payable to TrusteeCustodian	Text
Pretax Account Number	Text
Roth Account Number	Text
Address of TrusteeCustodian	Text
City-0	Text
State-0	Text
Zip-0	Text
Send direct rollover distribution check to	CheckBox
Send check to my address of record	CheckBox
The Form W4R Federal Tax Withholding Form is requi	CheckBox
Federal Income Tax Withholding for systematic payments (including RMD payments) lasting 10 years or more:_Opt-out	RadioButton
Federal Income Tax Withholding for systematic payments (including RMD payments) lasting 10 years or more:_Different#20#25	RadioButton
Date	Text
Not Applicable I certify I am not married andor t	CheckBox
Printed Name of Spouse	Text
Dated	Text
Dated-0	Text
State of	Text
in the country of	Text
ID Document	Text
Statements Verified	Text
Printed Name of Notary	Text
Dated-1	Text
My commission expires	Text
Was the participant an Offcer of the Company	CheckBox
Was the participant an Owner of the Company	CheckBox
Yes Percent Ownership-0	Text
Was the participant an Officer of the CompanyWas t_Was#20the#20participant#20an#20Officer#20of#20the#20CompanyWas#20t_Yes_On	RadioButton
Was the participant an Officer of the CompanyWas t_Was#20the#20participant#20an#20Officer#20of#20the#20CompanyWas#20t_No_On	RadioButton
Date of Termination	Text
Date of Final Payroll Deduction	Text
Current Year Hours Worked	Text
Prior Year Hours Worked	Text
I authorize the payment of retirement plan benefit	CheckBox
I authorize the payment of retirement plan benefit-0	CheckBox
I authorize the payment of retirement plan benefit-1	CheckBox
Printed Name	Text
Date-0	Text
Marital Status
Single	Radiobutton	Check this box if you are not married (legally single) at the time you complete this form.
Married	Radiobutton	Check this box if you are currently legally married.
Divorced	Radiobutton	Check this box if you are legally divorced and not currently married.
Widowed	Radiobutton	Check this box if your spouse has died and you have not remarried.
Participant Address & Contact
Phone Number	Text	Enter the participant's preferred daytime phone number including area code and extension if applicable.
Street Address	Text	Enter the participant's current mailing street address, including apartment or unit number if applicable.
City	Text	Enter the city of the participant's mailing address.
State	Text	Enter the U.S. state of the participant's mailing address (use the two-letter abbreviation or full state name).
ZIP Code	Text	Enter the participant's mailing ZIP code (5-digit ZIP or ZIP+4).
Email Address	Text	Enter the participant's primary email address to receive electronic communications about this request.
Contact by Telephone	Checkbox	Check this box if you want Nationwide to contact you by the telephone number of record (electing telephone contact instead of only electronic communications).
Contact by US Mail	Checkbox	Check this box if you want Nationwide to contact you via U.S. mail (electing postal mail contact instead of only electronic communications).
Participant Identity
Participant Name	Text	Enter the participant's full legal name as it should appear on plan and tax records.
Social Security Number (SSN)	Text	Enter the participant's nine-digit Social Security Number (SSN) exactly as issued.
Date of Birth	Date	Enter the participant's date of birth.
Date of Hire	Date	Enter the date the participant was hired by the employer.
Plan Information
Plan ID	Text	Enter the plan's assigned identification code or number used by your organization or Nationwide to identify this retirement plan.
Plan Name	Text	Enter the official name of the retirement plan as it appears in plan documents or on file with Nationwide.
401(k)	Checkbox	Check this box if the plan identified on this form is a 401(k) plan.
403(b)	Checkbox	Check this box if the plan identified on this form is a 403(b) plan.
457(b)	Checkbox	Check this box if the plan identified on this form is a 457(b) plan.
401(a) Profit Sharing	Checkbox	Check this box if the plan identified on this form is a 401(a) Profit Sharing plan.
401(a) Money Purchase	Checkbox	Check this box if the plan identified on this form is a 401(a) Money Purchase plan.
Pre-Tax Direct Rollover Options
N/A - No Pre-Tax contributions	Checkbox	Check this box if you have no pre-tax contributions and therefore no pre-tax funds to roll over.
Rollover of Pre-tax vested balance to a Traditional IRA	Checkbox	Check this box to direct Nationwide to roll your pre-tax vested balance into a Traditional IRA.
Rollover of Pre-tax vested balance to another eligible retirement plan	Checkbox	Check this box to direct Nationwide to roll your pre-tax vested balance to another eligible retirement plan (for example, a new employer's plan).
Rollover of Pre-tax vested balance to a Roth IRA	Checkbox	Check this box to convert and roll your pre-tax vested balance into a Roth IRA, understanding the distribution will be reported as taxable income for the year distributed.
Reason for Distribution (select one)
Termination of Employment	Radiobutton	Check this box when you are requesting a distribution because your employment with the Employer has ended.
In-Service Withdrawal	Radiobutton	Check this box when you are requesting an in-service withdrawal that is permitted under the plan while you remain employed.
Disability as defined within the Plan Document	Radiobutton	Check this box when you are requesting a distribution because you meet the plan’s definition of disability.
Withdrawal of After-Tax Voluntary Contributions	Radiobutton	Check this box when you are requesting a distribution of after-tax voluntary contributions from your account.
You are no longer employed with the Employer (footnote/explanation)	Radiobutton	Check this box when the distribution reason is that you are no longer employed with the Employer (note: transferring within the same controlled group does not constitute termination).
Withdrawal of Rollover Contributions	Radiobutton	Check this box when you are requesting a distribution of rollover contributions that were previously rolled into the plan.
Termination of the Plan (Employer initiated action)	Radiobutton	Check this box when the distribution is being requested because the employer is terminating the plan. NOTE Select only one distribution reason per submi_Termination of Employment_On NOTE Select only one distribution reason per submi_InService Withdrawal_On NOTE Select only one distribution reason per submi_Disability as defined within the Plan Document_On NOTE Select only one distribution reason per submi_Qualified Disaster Recovery Distribution QDRD_On NOTE Select only one distribution reason per submi_Withdrawal of AfterTax Voluntary Contributions_On
Reservist Called to Active Military Service Distributions	Radiobutton	Check this box when you are requesting a distribution pursuant to being a reservist called to active military service. NOTE Select only one distribution reason per submi_Termination of Employment_On NOTE Select only one distribution reason per submi_InService Withdrawal_On NOTE Select only one distribution reason per submi_Disability as defined within the Plan Document_On NOTE Select only one distribution reason per submi_Qualified Disaster Recovery Distribution QDRD_On NOTE Select only one distribution reason per submi_Withdrawal of AfterTax Voluntary Contributions_On
Other reason	Radiobutton	Check this box only if none of the listed reasons apply and provide the specific reason in the space on the form. NOTE Select only one distribution reason per submi_Termination of Employment_On NOTE Select only one distribution reason per submi_InService Withdrawal_On NOTE Select only one distribution reason per submi_Disability as defined within the Plan Document_On NOTE Select only one distribution reason per submi_Qualified Disaster Recovery Distribution QDRD_On NOTE Select only one distribution reason per submi_Withdrawal of AfterTax Voluntary Contributions_On
Repetitive Cash Payments - Schedule
Monthly	Checkbox	Check this box to select monthly as the frequency for repetitive cash payments.
Quarterly	Checkbox	Check this box to select quarterly (every three months) as the frequency for repetitive cash payments.
Semi-Annually	Checkbox	Check this box to select semi-annually (every six months) as the frequency for repetitive cash payments.
Annually	Checkbox	Check this box to select annually (once per year) as the frequency for repetitive cash payments.
Beginning Date	Date	Enter the date when the repetitive cash payments should begin. Fill only if 'Monthly', 'Quarterly', 'Semi-Annually', 'Annually' is 'Yes' if any. Depends on: Monthly, Quarterly, Semi-Annually, Annually
Gross Amount	Number	Enter the gross dollar amount to be paid for each repetitive payment (amount before taxes). Fill only if 'Monthly', 'Quarterly', 'Semi-Annually', 'Annually' is 'Yes' if any. Depends on: Monthly, Quarterly, Semi-Annually, Annually
Roth Direct Rollover Options
N/A - No Roth Contributions	Checkbox	Check this box if you have no Roth contributions and do not want to direct any Roth funds to a rollover.
Rollover of Roth account balance to a Roth IRA	Checkbox	Check this box if you want your Roth account balance directly rolled over into a Roth IRA.
Rollover of Roth account balance to another 401(k), 403(b) or governmental 457(b) plan's Roth Rollover account	Checkbox	Check this box if you want your Roth account balance directly rolled over into another employer plan’s Roth rollover account (such as another 401(k), 403(b), or governmental 457(b) plan).

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