EMPLOYER’S NAME EMPLOYER NUMBER
EMPLOYER’S ADDRESS Number and Street City State Zip Code
PARTICIPANT’S NAME
LAST 4 DIGITS OF SOCIAL SECURITY NUMBER
PARTICIPANT’S TELEPHONE NUMBER
XXX-XX-
__ __ __ __
( )
PARTICIPANT’S ADDRESS Street and Number City State Zip Code
PLAN(S)
SIMPLE IRA
Tax-Deferred Annuity
401(k)
403(b) Thrift
Simplified Employee Pension
Gov. 457 Plan
Individual Retirement Annuity
Flexible Premium Annuity
401(a) Thrift Plan
REPORT OF
TERMINATION, RETIREMENT, DEATH
mutualofamerica.com
6270.L 10/12
MARITAL STATUS OF DECEASED PARTICIPANT
Please send this form to your local service representative.
If you require address information, please call Mutual of America’s toll-free telephone number 1-800-468-3785.
Last Day of
Employment:
Month Day Year
/ /
Date of Last
Contribution:
Month Day Year
/ /
REASON FOR CESSATION OF PARTICIPATION
Single
Married
Widowed
Divorced
Termination of Service
Disability
Retirement
Death
SPOUSE’S FULL NAME
_______________________________________________________
SPOUSE’S ADDRESS (If different from deceased participant’s) Number and Street
_______________________________________________________
City State Zip Code
EMPLOYER’S SIGNATURE
SIGNATURE DATE
Vesting
Percentage: _________%
MUTUAL OF AMERICA LIFE INSURANCE COMPANY, 320 PARK AVENUE, NEW YORK, NY 10022-6839
Catholic Charities of St. Louis
