A disclaimer is generally any statement intended to specify or delimit the scope of rights and obligations that may be exercised and enforced by parties in a legally recognized relationship.

Agree

1. Account Information

Your Name:

Account Number:

I am:

NOT MarriedMarried

Email Address:

Date of Birth:

Social Security Number:

Type of Account:

401k Traditional401k ROTH

Phone Number:

Employer Name:

EIN:

Is this a distribution due to death?

No - Skip Beneficiary YES - Please complete the Beneficiary Details

Beneficiary Details

Beneficiary Name: Beneficiary Date of Birth:	Beneficiary SSN: Beneficiary Phone Number:
Beneficiary Home Address:	Beneficiary City:
Beneficiary State:	Beneficiary Zip:

5. Funding Instructions

Send funds via:

ACH ($5,000 limit)WIRECHECK

For ACH/WIRE – Please complete the info below

Bank Name

ABA Routing Number

Account Holder Name

Account Number

For Credit To

For Check – Please complete the info below

Make Check Payable To

Mail Check To

Address

City

State

Zip

Send Check via: If payment is over $5,000 it will be mailed certified mail unless marked otherwise below

Regular MailCertified MailHold for pick upOvernight Mail

6. Signatures and Acknowledgement

The distributions you receive from your individual qualified account established at this institution are subject to federal income tax withholding unless you elect not to have withholding apply. You may elect not to have withholding apply to your distribution payments by completing the "Withholding Election" section above. If you do not complete the "Withholding Election" section by the date your distribution is scheduled to begin, federal income tax will be withheld from the amount withdrawn at a rate of 20%. If you elect not to have withholding apply to your distribution payments, or if you do not have enough federal income tax withheld from your distribution, you may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient.

I certify that I am the proper party to receive payment(s) from this 401k, and that all information provided by me is true and accurate. I acknowledge that I have read the Notice of Withholding and have completed the Withholding Election above. I further certify that no tax advice has been given to me by the Administrator, Custodian, or Trustee, that distributions (except certain transfers) are reported to the IRS, and that all decisions regarding this withdrawal are my own. I expressly assume the responsibility for any adverse consequences which may arise from this withdrawal and I agree that the Administrator, Custodian, Trustee shall in no way be responsible for those consequences.

The above request is hereby approved, and the Administrator is authorized to distribute the participant’s benefits in accordance with such request.

Print Name

Signature

Date