Step 1 of 3: Supply Information | Step 2 of 3: Confirm Entries | Step 3 of 3: Submission Confirmation
  • Please supply the information requested below.
  • Read all agreements on this form before submitting.
  • Fields having an asterisk notation are required.

Transaction Type:
*Type: Cash disbursement due to a permanent disability. For more details, please visit our Transaction Information page or contact Tax Deferred Solutions.

Employee Information

*Last Name:    *First Name:    MI: 
Maiden/Former Name:   
* Address:
* City: * State:   * Zip:
* Phone: Alternate Phone:
* Email: * Re-enter Email:
* SS#: (9 digits, no dashes or spaces) * Date of Birth: (MM/DD/YYYY)
*Date of Disability:

Service Provider Agent Information:

Distributing Account Information:

Please provide the information for the employer from whose Plan you wish to withdraw funds:
*Employer Name: Current Employer Name (if different than account sponsor):

Please provide the following information for the Service Provider who will be distributing (paying out) the funds for this transaction:

*Service Provider Company:
If other, please supply company name here:
Account #:
*Amount Requested:

By clicking the button below labeled "Continue", I hereby confirm that the information on this form is correct and complete to the best of my knowledge.

*Re-enter Social Security # to verify:

Additional instructions will appear on the next screen    

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