Fbc - Outgoing Exchange Form

Outgoing Exchange Form SDCOE / Fringe Benefits Consortium (FBC) Instructions

• Submission of this form initiates a Exchange from your FBC Nationwide account, an approved vendor, to another approved vendor within the Fringe Benefits Consortium 403(b) Program. • The receiving vendor must be listed as a current approved vendor (authorized investment company) on fbcretire.com. • Please allow 14-21 days for delivery assets after form has been received and determined to be in good order. • Upon completion of this form please fax a copy to 1-800-597-8206

Employee Employee Name Information Mailing Address

Social Security Number

Current Date

School District

Home Phone Number

Date of Birth

Marital Status Married

(Street)

(City,State,Zip)

Single

Total withdrawal (all funds and all sources)

Amount of Withdrawal

Receiving Vendor Information

Partial withdrawal: Plan: Plan:

457(b) 457(b)

403(b) 403(b)

401(a) 401(a)

Roth 403(b) Roth 403(b)

Fund / ID Fund / ID

$ $

Plan:

457(b)

403(b)

401(a)

Roth 403(b)

Fund / ID

$

Name of Financial Institution: Please contact the receiving financial i tit ti to institution t ensure correct address and acceptance.

Attention of: Plan / IRA Account Number: Address: City/State/Zip Code: Phone:

Delivery Method

If no delivery method is indicated, funds will be sent via regular US Mail. Please note that P.O. Boxes cannot receive overnight deliveries. US Mail Overnight delivery - An additional $20.00 fee will be deducted from my Nationwide account per occurrence. Wire* - An additional $20.00 fee will be deducted from my Nationwide account per occurrence. Bank Name:

*Bank account information must be completed for wire deposit. Please attach a voided check or deposit slip.

Bank City and State: Name on account: Routing Number: Account Number:

Employee Signature

By executing this form I hereby request and consent to the above withdrawal.

Employee Signature (required)

Date

Signature Guarantee (required)

Date

FBC Authorized Signature (required)

Date

For FBC Use Only

County Schools Fringe Benefits Consortium - 6401 Linda Vista Road, Room 506, San Diego, CA. 92111