Fillable CARES Act Withdrawal Request (NL) 1. Retirement Plan

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CARES Act Withdrawal Request (NL) 1. Retirement Plan

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SRS 21481 Page 1 - Continued on next page
(7/20)
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CARES Act Withdrawal Request (NL)
Standard Retirement Services, Inc.
1100 SW Sixth Avenue P9A Portland OR 97204-1020
Phone: 800.858.5420 Fax: 888.418.6806
If you have questions about your request, call 800.858.5420 or email savings@standard.com.
1. Retirement Plan Information
COMPLETE THE FOLLOWING (REQUIRED)
Plan Name ___________________________________________________________________________________
Plan Number: ____ ____ ____ ____ ____ ____
You can nd your plan name and number on your quarterly account statement or on Personal Savings Center at
standard.com/login. Once you log in, choose My Plan, About Me and My Plan from the menu to see this information.
Your plan administrator should also have this information available.
2. Participant Verication
Participant First Name _________________________ Middle Initial ______ Last Name ______________________________
Address of Record ______________________________________________________________________________________
City _______________________________________________________State ____________________ ZIP ______________
SSN _______ - ______ - _________ Note: This is the SSN that is on file with your employer and is used to submit taxes.
Date of Birth
________ / ______ / _________
3. The Amount of Your Distribution
Up to $100,000 can be withdrawn from a qualied plan, 403(b) or 457(b) governmental plan as a coronavirus-related
distribution in 2020. This applies to a participant, spouse, or dependent who is diagnosed with the virus or if you as an
individual have experienced adverse nancial consequences due to the virus, including quarantine, furlough, layo or
reduced work hours, lack of childcare, closing or reduced hours of a business owner/operator.
CHECK ONLY ONE:
Total Withdrawal Requested: $________________ (not to exceed $100,000)
Withdrawal Maximum Available In My Account
Optional repayment of distributions
A coronavirus-related distribution may be repaid within three years of the date of distribution and may be made in
increments not to exceed the amount of the distribution that would otherwise be eligible for rollover. If you have questions,
please call 800.858.5420 or email savings@standard.com.
Reset
SRS 21481 Page 2 - Continued on next page
(7/20)
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4. Tax Instruction
A. Federal Taxes
The IRS requires us to apply withholding on any taxable distribution. For U.S. citizens or residents, the minimum federal
withholding rate of 10 percent will apply. You may elect to have no federal taxes withheld or you may elect a higher rate
of withholding. If you do not indicate a rate or choose not to have federal taxes withheld, we must withhold 10%.
Income tax on the taxable portion of the distribution may be spread over a three-year period. You can choose whether
you would like taxes withheld at this time of this distribution or not.
Do not withhold federal taxes

Withhold federal taxes at the rate of % (must be at least 10% and a whole number)
For Non-Resident Aliens, an additional taxation may apply. Please submit an IRS Form W-8 BEN.
B. State Taxes
Required state income tax may be withheld from your distribution. In some cases, you may elect not to have the
withholding apply or you may elect to increase the rate of withholding. In other cases, state income tax withholding is
not required. If you do not make an election below, a tax rate will be applied based on the state in which you live. This is
determined by using the address we have for you on le.

Do not withhold state taxes unless required by your state

Withhold state taxes % (must be at your state’s minimum and a whole number)
5. Delivery Instructions
If your name or address has changed within the last 14 days, there will be a delay in processing. Delivery method
does not aect processing time. Incomplete requests will delay processing.
A. Regular Mail
My address is outside the U.S. or its territories. I have included my IRS Form W-9 or W-8 BEN with this
request. Note: If not attached, this request will be canceled and you will need to resubmit with the correct
forms.
B. Overnight
Use next business day delivery to send my check. An additional fee will be deducted from my account. Next
business day delivery is not available for PO boxes. A street address must be supplied, or the check will be
sent via USPS mail.
Please note:
If you need to permanently change your address of record, please do so with your employer.
Plan Number:
_______________________________ Participant Name: _____________________________________
SRS 21481 Page 3 - Continued on next page
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Plan Number: _______________________________ Participant Name: _____________________________________
6. Required Signatures
A. Participant Self-Certication
Certication: I acknowledge receipt and understand the terms and conditions relating to the payment and tax
implication of my taxable benets from the plan as explained in the Special Tax Notice Regarding Plan Payments.
I also understand that any securities holdings that I have in my account will be sold once I submit this form, and I
agree to this liquidation in order to process my distribution. I certify that the above information is true and correct to
the best of my knowledge. I understand the trustee of the plan will rely on this information in making the distribution
that I have requested. I hereby consent to the payment of my vested account balance.
I certify that I meet at least one of the following conditions: (1) I was diagnosed with the virus SARS-CoV-2 or
with coronavirus disease 2019 (referred to collectively as COVID-19) by a test approved by the Centers for
Disease Control and Prevention (including a test authorized under the Federal Food, Drug, and Cosmetic Act);
(2) my spouse or my dependent was diagnosed with COVID-19 by a test approved by the Centers for Disease
Control and Prevention (including a test authorized under the Federal Food, Drug, and Cosmetic Act); or (3) I
have experienced adverse nancial consequences because: (i) I, my spouse, or a member of my household was
quarantined, furloughed or laid o, or had work hours reduced due to COVID-19; (ii) I, my spouse, or a member
of my household was unable to work due to lack of childcare due to COVID-19; (iii) a business owned or operated
by me, my spouse, or a member of my household closed or reduced hours due to COVID-19; or (iv) I, my spouse,
or a member of my household had a reduction in pay (or self-employment income) due to COVID-19 or had a job
oer rescinded or start date for a job delayed due to COVID-19.
X
Participant signature
X
Date
Please return this form to your Plan Administrator for authorization and submission.
SRS 21481 Page 4 (7/20)
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B. DIRECTION AND ACKNOWLEDGMENT OF PLAN ADMINISTRATOR
TO BE COMPLETED BY THE PLAN ADMINISTRATOR ONLY
I, in my capacity as Plan Administrator of the above named retirement plan, direct Standard Retirement Services,
Inc. (SRS) to process the distribution listed above and acknowledge that SRS is not acting as the Manager of the
Approval Process (MAP) or as an Administrative Fiduciary for this distribution.
I represent that I am an authorized signer on behalf of the above-named plan and have authority to instruct the
service provider to process this form. By signing this authorization request, I will be responsible for the
oversight and authorization of this transaction.
Plan administrator’s name (printed)
X
Plan administrator signature
X
Date
Administrator, Please Submit This Form By One Of The Methods Below
● Email: Email benetrequests@standard.com. Include this form and any other related documents as a single
attachment to your email. This email is for receiving forms and is not monitored for questions.
● Mail: Send your form and any other related documents to 1100 SW Sixth Avenue P9A, Portland, OR 97204-1020.
● Fax: Send this form and any other related documents as a single fax to 888.418.6806.
Plan Number:
_______________________________ Participant Name: _____________________________________
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CARES Act Withdrawal Request (NL) 1. Retirement Plan

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Completed 11 October 2020

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