IRA MINIMUM DISTRIBUTION WITHDRAWAL
Name:
Phone #:
Contract #:
Social Security #:
Address:
Street.
City
State
Zip
I would like to receive my distribution on an annual basis on the 1st of: (Please check one month only)
January
February
March
April
May
June
July
August
September
October
November
December
Withhold Federal Income Tax. Amount to be withheld: (% or $):
I would like a different distribution schedule:
Monthly, beginning in:
(for monthly withdrawals, please include a Direct Deposit Authorization form)
Quarterly, beginning in:
Semi-Annually, beginning in:
Withhold Federal Income Tax. Amount to be withheld: (% or $):
I understand that it is still my responsibility to make sure that I have taken and received my minimum distribution each year.
Annuitant Signature
Date
National Slovak Society of the USA 351 Valley Brook Rd, McMurray, PA 15317-3337 Telephone (724)731-0094 Fax (724)731-0145 www.nsslife.org
FORM # IRA-MDW – 003 G
05/01/2015