Form Sbs008 – Fill Out and Use This PDF

PARTICIPANT INFORMATION

Previous Provider Information:

As an authorized representative of the previous provider, I acknowledge that the amount to be transferred/rolled over consists of pre-tax contributions and earnings from an eligible retirement plan as described in IRC Section 402(c).

Amount of Transfer / Direct Rollover: $_________________________ (Enter approximate amount if exact amount is not known.)

Required minimum SBS-AP Incoming Transfer amount is $200.

Investment Option Information: The incoming transfer/direct rollover will be invested in the SBS-AP fund option(s) as indicated below. Please refer to the Supplemental Annuity Plan portion of the Alaska Division of Retirement and Benefits Web site or call the Division at (800) 821-2251 or (907) 465-4460 for information on these investment options.

Note — Transfers into the SBS-AP are only allowed for participants having an existing SBS-AP account balance that resulted from direct participation in the SBS-AP through an SBS-AP participating employer.

PARTICIPANT ACKNOWLEDGEMENTS

General Information — I understand that only certain types of distributions are eligible for transfer/rollover treatment and that it is solely my responsibility to ensure such eligibility. By signing below, I affirm that the funds I am transferring/rolling over are in fact eligible for such treatment.

I understand funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund’s prospectus or other disclosure documents. I will refer to the fund’s prospectus and/or disclosure documents for more information.

I authorize these funds to be transferred into my SBS-AP account and to be invested according to the information specified in the Investment Option Information section.

If the investment option information is missing or incomplete, I authorize the Service Provider to allocate the transfer/direct rollover assets (“assets”) the same as my ongoing contributions. If my assets are received more than 180 calendar days after the Service Provider receives this Incoming Transfer/Direct Rollover form (this “form”), I authorize the Service Provider to allocate all monies received the same as my ongoing allocation election on file with the Service Provider. I understand that this completed form must be received by the Alaska Division of Retirement and Benefits at the address below.

I understand that the current Custodian/Provider may require that I furnish additional information before processing the transaction requested on this form, and Service Provider is not responsible for determining the status of any transaction that I have requested. It is entirely my responsibility to provide the current Custodian/Provider with any information that they may require, and/or to notify Service Provider of any information that the current Custodial/Provider may wish to obtain in order to effect the transaction.

Withdrawal Restrictions — I understand that the Internal Revenue Code and/or the SBS-AP Plan Document may impose restrictions on transfers, direct rollovers and/or distributions. I understand that I must contact the Plan Administrator (Alaska Division of Retirement and Benefits) to determine when and/or under what circumstances I am eligible to receive distributions or make transfers/direct rollovers.

Investment Options — I understand that by signing and submitting the form for processing, I am requesting to have investment options established under the Plan as specified on the first page of this form. I understand and agree that this account is subject to the terms of the SBS-AP Plan Document. I understand and acknowledge that all payments and account values, when based on the experience of the investment options, may not be guaranteed and may fluctuate, and upon redemption, shares may be worth more or less than their original cost. I acknowledge that investment option information, including Investment Option Detail sheets, disclosure documents and prospectuses, have been made available to me and I understand the risks of investing.

Account Corrections — I understand that it is my obligation to review all confirmations and quarterly statements for discrepancies or errors. Corrections will be made only for errors which I communicate within 90 calendar days of the last calendar quarter. After this 90 days, account information shall be deemed accurate and acceptable to me. If I notify Service Provider of an error after this 90 days the correction will only be processed from the date of notification forward and not on a retroactive basis.

PAYMENT INSTRUCTIONS

Required Signatures — My signature indicates that I have read, understand the effect of my election and agree to all pages of this Incoming Transfer/Direct Rollover form. I affirm that all information provided is true and correct.

I acknowledge and agree that the Plan Administrator/Trustee for the Previous Employer’s Plan is released from and the Plan Administrator/ Trustee for the Current Employer’s Plan shall assume all obligations associated with any amounts transferred under this Incoming Transfer/Direct Rollover form.