| 403(b) Contribution Planner® | RetirementWorks® | Web Calcs | Downloads | Lump Sum Distributions

			About the plan participant: Name: Date of birth (mm/dd/yyyy): Tax year: February to January March to February April to March May to April June to May July to June August to July September to August October to September November to October December to November January to December Filing Status: Single Married Filing Jointly Married Filing Separately Head of Household Estimated taxable income (EXCLUDING this distribution) for the current tax year: $ About the Distributable Amount: Type of Plan: 401(k) / 401(a) / Misc. def. contr. 403(b) IRA / Simple IRA / SEP IRA 457 Plan Defined Benefit Total distribution amount: $ Date of distribution (mm/dd/yyyy): Total after-tax contributions: $ Cumulative prior PS-58 costs: $ Total prior loans treated as taxable income: $ Net unrealized appreciation on employer securities: Basis: $ Market value: $ Check if 5 or 10 year averaging, or capital gains treatment or pre-1974 amounts has EVER been used.
			Still River Retirement Planning Software, Inc. · 69 Lancaster County Rd., Harvard, MA 01451 · (978) 456-7971 · Fax: (978) 456-7972 · E-mail: info@stillriverretire.com