Reason for the Withdrawal: Verification for the reason chosen needs to be faxed to "Distribution Request" at 513.357.3199. Failure to provide verification can delay the processing of your request. (choose one)

Age 70½: I have attained age 70½.

Severance of Employment:

I separated from service on (MM/DD/YYYY)

De minimus amount: In accordance with the Plan terms, I may elect a "de minimus" distribution of up to $5,000 provided: (i) My Account does not exceed $5,000; (ii) I have not made any Salary Reduction Contribution or received any Employer contribution to my Account during the prior two years ending on the date I would receive the de minimus distribution; and (iii) I have not previously taken a de minimus distribution from the Plan.

Transfer/Rollover Distribution:

I elect to move funds to another approved product provider within the Plan (choose one):
Transfer to another Plan approved 457 product provider
Rollover to a non-457 plan


Information on Transfer/Rollover:

I verify that the product provider designated below is a proper recipient for my transfer/rollover.

Name of Product Provider

Unforeseeable Emergency : 

Resulting from one of the following:
Illness or accident of participant, beneficiary, spouse, or dependents
My loss of property due to casualty
Other extraordinary and unforeseeable circumstance beyond my control (describe):