Date

Transaction Request

A separate request must be submitted for each investment company.

One request may be submitted for multiple transactions at one company if all account numbers are listed.

Basic Information

Client First Name *

Client MI

Client Last Name *

Former or Current Employer *

Transaction Type *

New Employer *

Distribution Reason (matches qualifying event on transaction paperwork) *

Rollover Reason (matches qualifying event on transaction paperwork) *

Reason for Hardship *

Medical expenses

Purchase of principal residence

Post-secondary education expenses

Prevent eviction or foreclosure

Funeral expenses

Repair of principal residence

Other Other

Submitter Details

Person Submitting Request *

Employee

Employee's Financial Advisor

Other - Indicate Name and Role Other - Indicate Name and Role

Employee Phone *

Financial Advisor Name *

Financial Advisor Email *

Financial Advisor Phone *

Other Submitter Email *

Other Submitter Phone *

Employee Information

Social Security Number *

Date of Birth * +

You Selected Age 59 ½+ as the Transaction Reason *

I have confirmed my date of birth above.

Potential discrepancy with age 59 ½+ selection

Processing delays could result

Please confirm date of birth and transaction reason

Send Confirmation Email to Employee (In Addition to Submitter)? *

Yes

No

Employee Email *

Date of Disability * +

Child's Name *

Employment Separation Date +

403(b)/457(b) Account Information

Investment Company Name *

Investment Account/Contract Number *

From Investment Company Name *

From Account/Contract Number *

To Investment Company Name *

To Account/Contract Number *

Additional Documentation (PDFs Only)

If submitting a fillable PDF form, print to PDF format and then save that document and attach it here. (Depending on the software used, file content may not be included if you simply save a fillable PDF form and upload.)

To print to PDF, select print (or click CTRL+P) and then select a print to PDF printer option.

*

Attach the following documentation (select the file or drag & drop):

• Transaction forms from your investment company

• Transaction forms from your investment company (the "from" investment company above)

• Death certificate

• Birth certificate or adoption certificate

• Hardship Self-Certification Form or documentation of hardship-related expenses

• Documentation of disability

• Certified copy of court's QDRO

Delivery Instructions

Aviben's practice is to send the voucher to the appropriate investment company. Please provide delivery instructions if the voucher should be sent elsewhere.

0/120 characters

Affirmation

I affirm that the information I have provided is accurate and complete. *

Yes, I affirm.

Signature *

clear