Transamerica 401K Withdrawal – Fill Out and Use

Distribution Request Form

READ THE ATTACHED IRS SPECIAL TAX NOTICE: IF YOUR PLAN ALLOWS FOR AN ANNUITY OPTION, READ THE WRITTEN EXPLANATION OF QUALIFIED JOINT AND 50% CONTINGENT SURVIVOR ANNUITY FORM OF BENEFIT BEFORE COMPLETING THIS FORM.

Please note: Do not use this form for:	(1)	Death Benefit Claim
	(2)	Required Minimum Distribution
	(3)	Hardship Withdrawal Request

INSTRUCTIONS AND INFORMATION FOR COMPLETING THIS FORM

This Form Must Be Completed And Signed By You (And Your Spouse If You Are Married And Your Plan Allows For Annuities) And The Plan Administrator, Trustee Or An Authorized Signer. If any information is missing or incomplete, you may be required to complete a new form or provide additional information before the distribution can be processed.

PARTICIPANT INSTRUCTIONS

1.Complete Sections A-H. If you do not have a Roth 401(k) Account, skip Section D. If you are married and your plan allows for annuities, complete Section H, Spousal Consent.

2.Your signature is required in Section I.

3.Submit this form to your Employer for signature and processing. DoUnot mailUthis form directly to the Processing Center listed at the end of this form.

EMPLOYER INSTRUCTIONS

1.Complete Section J.

2.Your signature is required in Section J.

3.Submit this form to the Processing Center

SECTION A. Participant Information — Please print

Company/Employer Name		Contract Number

Street Address/Apt. No.

Phone No.

Ext. (if any)

(

)

–

City

State

Zip Code

Marital Status

Married

Not Married

MAIL DELIVERY OF DISTRIBUTIONS

If no address is provided in Section A, the address on file will be used to process this request. All checks will be sent via First Class Mail unless the Overnight Mail box is checked below.

Send check overnight mail and deduct $25.00 from the check for express charges. $50.00 will be deducted when two checks are required. (Example: One check sent to a rollover institution and one check to the participant). Please note: A street address must be provided.

Based on plan provisions, a distribution fee may be assessed at the time of processing. Please check with your Plan Administrator for any questions as to if a distribution fee may apply to your request.

SECTION B. Reason For Distribution Request — Must be completed OR skip this section if your employer checked off “plan termination” in Section J

– –

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SECTION C. Form of Payment For Traditional 401(k) Account - Only choose one of the three options

¹Partial amount to be rolled over: $___________________

Direct Rollover to: (Select Only One)

_____ AN IRA OFFERED THROUGH Transamerica (Minimum rollover amount is $5,000). If you are interested in the Rollover IRA option

through Transamerica, call (866) 691-0030 to learn more and to establish an account. An IRA account number is required before the rollover can be processed.

_____ AN ELIGIBLE RETIREMENT PLAN (401(a), 401(k), 403(b), and Governmental 457)

_____ AN IRA

	NEW ACCOUNT INFORMATION:	MAILING ADDRESS:
	IRA Account Number (Required) / Plan Name	Name of Trustee or Custodian for the New Plan or IRA
	Make Check Payable To:	Address – Number & Street
		City	State	Zip Code

²Option 2 (Combination) - I am requesting a distribution of my Traditional 401(k) account to be paid partially to me and partially as a Direct Rollover.

I understand that the portion payable to me may be subject to 20% federal income tax withholding.

Distribute __________% of my Traditional 401(k) account:

____________% of the above paid directly to me, and

____________% of the above applied to the Direct Rollover Account indicated below.

The above two percentages must equal 100%

Direct Rollover to: (Select Only One)

_____ AN IRA OFFERED THROUGH Transamerica (Minimum rollover amount is $5,000). If you are interested in the Rollover IRA option

through Transamerica, call (866) 691-0030 to learn more and to establish an account. An IRA account number is required before the rollover can be processed.

_____ AN ELIGIBLE RETIREMENT PLAN (401(a), 401(k), 403(b), and Governmental 457)

_____ AN IRA

NEW ACCOUNT INFORMATION:	MAILING ADDRESS:
IRA Account Number (Required) / Plan Name	Name of Trustee or Custodian for the New Plan or IRA

		City	State	Zip Code
	Option 3 (Cash) - I am requesting a distribution of	all or a	partial amount of my Traditional 401(k) account. I am not electing a Direct

Rollover of any portion of the distribution. I understand the check will be made payable to me and that the portion payable to me may be subject to 20% federal income tax withholding.

¹Partial amount to be paid directly to me: $_____________

¹Actual Value of the distribution may vary based on the final market closing price at the time the distribution is processed, and any applicable processing fees.

PARTIAL DISTRIBUTION AMOUNTS -I understand that if I choose a partial amount in the options above, I am responsible for ensuring that partial distributions are completed by the shorter of my life expectancy or 15 years after the first partial distribution is made to me, as required by the Plan. I also understand that if I choose this option I may lose favorable tax treatment on my distributions

²DIRECT ROLLOVER

In a Direct Rollover, an eligible rollover distribution is paid from your retirement plan directly to an IRA or your new Employer's 401(a), 401(k), 403(b) or governmental 457 Plan. An IRS Form 1099-R will still be completed and submitted to the IRS; however, no federal or state income tax is withheld from amounts directly rolled over. The Direct Rollover check will be made payable to the IRA/plan trustee or custodian for the benefit of the participant or alternate payee unless otherwise indicated above.

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SECTION D. Form of Payment For A Roth 401(k) Account – Complete only if your plan allows for Roth Contributions. Only choose one of the three options

¹Partial amount to be rolled over: $___________________

Direct Rollover to: (Select Only One)

_____A ROTH IRA OFFERED THROUGH Transamerica. (Minimum rollover amount is $5,000.) If you are interested in the Rollover IRA

option through Transamerica, call (866) 691-0030 to learn more and to establish an account. An IRA account number is required before the rollover can be processed.

______A DESIGNATED ROTH ACCOUNT (401(k) or 403(b)) OR ROTH IRA

NEW ACCOUNT INFORMATION:	MAILING ADDRESS:
Roth IRA Account Number (Required) / Plan Name	Name of Trustee or Custodian for the New Roth 401(k) or Roth IRA

City

State

Zip Code

²Option 2 (Combination) - I am requesting a distribution of my Roth 401(k) account to be paid partially to me and partially as a Direct Rollover.

I understand that the portion payable to me may be subject to 20% federal income tax withholding.

Distribute __________% of my Roth 401(k) account:

____________% of the above paid directly to me, and

____________% of the above applied to the Direct Rollover Account indicated below.

The above two percentages must equal 100%

Direct Rollover to: (Select Only One)

_____ A ROTH IRA OFFERED THROUGH Transamerica. (Minimum rollover amount is $5,000.) If you are interested in the Rollover IRA

option through Transamerica, call (866) 691-0030 to learn more and to establish an account. An IRA account is required before the rollover can be processed.

_____ A DESIGNATED ROTH ACCOUNT (401(k) or 403(b)) OR ROTH IRA

NEW ACCOUNT INFORMATION:	MAILING ADDRESS:
IRA Account Number (Required) / Plan Name	Name of Trustee or Custodian for the New Plan or IRA

		City	State	Zip Code
	Option 3 (Cash) - I am requesting a distribution of	all or a	partial amount of my Roth 401(k) account. I am not electing a Direct Rollover of

any portion of the distribution. I understand the check will be made payable to me and that the portion payable to me may be subject to 20% federal income tax withholding.

¹Partial amount to be paid directly to me: $___________

¹Actual Value of the distribution may vary based on the final market closing price at the time the distribution is processed, and any applicable processing fees.

DISTRIBUTION AMOUNTS -I understand that if I choose a partial amount in the options above, I am responsible for ensuring that partial distributions are completed by the shorter of my life expectancy or 15 years after the first partial distribution is made to me, as required by the Plan. I also understand that if I choose this option I may lose favorable tax treatment on my distributions

²DIRECT ROLLOVER

In a Direct Rollover, an eligible rollover distribution is paid from your retirement plan directly to an IRA or your new Employer's 401(a), 401(k), 403(b) or governmental 457 Plan. An IRS Form 1099-R will still be completed and submitted to the IRS; however, no federal or state income tax is withheld from amounts directly rolled over. The Direct Rollover check will be made payable to the IRA/plan trustee or custodian for the benefit of the participant or alternate payee unless otherwise indicated above.

For participants required to take a minimum distribution during the current year that was not satisfied, please note the following: Your required minimum distribution (RMD) for the current year will need to be completed and made payable to you prior to the processing of your direct rollover request.

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SECTION E. Annuity Request (Not applicable to vested account under $5000 or if your plan does not offer annuities)

Skip this section if you made an election in Section C or D.

By selecting this option your entire account balance will be distributed in order to purchase the annuity

Annuity: If the plan offers annuities as a form of benefit payment, I elect payment as a monthly annuity with payments to commence ___________________.

Upon my death, my spouse’s payments should be _____% (from 50% to 100%) of my payments. My spouse’s date of birth is _________________. Such

annuity will be a Joint and Contingent Survivor Annuity if I am married and a Single Life Annuity if I am not married. I also understand that if I am married, my spouse need not consent to this election if I choose a Qualified Joint and Contingent Survivor Annuity (“QJSA”).

SECTION F. Outstanding Loan Payoff Instructions — Skip this section if you do not have an outstanding loan or are requesting an In-Service Withdrawal, Withdrawal of After Tax Contributions, 591/2 Withdrawal or a QDRO.

One of the following will occur if you have an outstanding loan amount and your reason for a distribution request in Section B is for Termination of Employment, Disability or a Retirement Benefit.

♦Your Loan will be considered paid in full if you have submitted your payment for the outstanding loan amount to your employer or have attached a money order or cashier’s check to this form.

♦Your outstanding loan balance will default and become taxable to you if Transamerica receives this form and your payment has not been received and processed.

SECTION G. Income Tax Withholding

The income tax withholding requirements vary depending on whether or not the distribution requested is an eligible rollover distribution. Please see the attached Special Tax Notice for the definition of eligible rollover distribution and a detailed explanation of the federal income tax withholding rules. If you request a Direct Rollover, no federal income tax will be withheld from the amount directly rolled over.

FEDERAL INCOME TAX

Eligible Rollover Distributions:

•If you request a Direct Rollover, no federal income tax will be withheld from the amount directly rolled over.

•If you request any portion that is an Eligible Rollover Distribution and payable to you: 20% mandatory federal income tax withholding will apply if the taxable amount of the distribution is more than $200 unless paid over 10 or more years.

STATE INCOME TAX

If your address of record is within a mandatory withholding state, state taxes will be withheld from your distribution in accordance with the respective state rules. Other states allow an independent election and in these states, state tax will be withheld unless you elect otherwise. If your state does not allow withholding, no state tax can be withheld. Please consult a tax advisor or Transamerica if you have questions regarding state tax withholding.

Do not withhold state income tax (ONLY IF INDEPENDENT ELECTION IS PERMITTED).

Withhold state income tax:__________% (If your state requires a greater withholding percentage than what you have indicated, the mandatory state

tax will apply).

SECTION H. Spousal Consent

Check with your Employer/Plan Administrator or Summary Plan Description to determine whether your plan is subject to spousal consent requirements. If spousal consent is required, complete this section. If your plan is not subject to spousal consent requirements, skip to Section I. Please note: You must have your spouse’s signature notarized or have a plan representative witness your spouse’s signature if your vested account balance is greater than $5,000 and your plan provides for joint and survivor annuities. However, if your vested account balance is less than $5,000 spousal consent is not required.

Spousal Consent

I, the undersigned spouse of the participant, have read the “Special Tax Notice Regarding Payments From Qualified Plans” provided to me and understand the effects of the waiver. I understand that federal law requires that the retirement benefit of my spouse must be paid under a Qualified Joint and Survivor Annuity Form as described in the attached “Special Tax Notice Regarding Payments From Qualified Plans,” unless I consent otherwise in writing to another benefit form. I hereby consent to the waiver of the annuity and consent to the form of benefit elected by my spouse.

Signature of Participant’s Spouse:

Date:

Statement of Plan Representative or Notary Public

The spouse whose signature I have witnessed is known to me and signed this form in my presence.
Plan Representative:			Date:
Notary Public Signature:			Date:

PLACE SEAL HERE (if applicable)

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SECTION I. Participant Signature

My signature acknowledges that I have read, understand and agree to all the terms of this Distribution Request form, and affirm that all information that I have provided is true and correct. Further, I acknowledge that I have received the “Special Tax Notice Regarding Payments From Qualified Plans” and other required notices. The above information is true and correct to the best of my knowledge. I further understand that I may revoke this election at any time prior to the distribution taking place.



Signature of Participant

Date

PARTICIPANT: RETURN COMPLETED FORM TO YOUR PLAN ADMINISTRATOR FOR PROCESSING

Section J. For Completion by Plan Administrator, Trustee Or Authorized Signer Only

Plan Name

The Participant is entitled to a vested benefit of% of company matching contributions.

The Participant is entitled to a vested benefit of _______________________% of profit sharing contributions.

The Number of hours worked in the Plan Year of Termination: __________________

Please refer to your Plan Document for the vesting schedule. If this information is not provided, the distribution will be processed with the data in Transamerica’s recordkeeping system.

By signing below, I hereby authorize Transamerica to process the distribution described in this form. This request is in compliance with plan provisions.

If spousal consent is not provided, then in accordance with the terms and provisions of the plan and under the current law, spousal consent is not required for payment of the requested benefit.

If this request is for a disability distribution, I certify that the participant meets the requirements of Section 72(m)(7).

Only submit this form after final contributions and loan repayments have been processed for termination distributions

Once this form has been completed with all of the necessary information and required signatures, please forward to the Processing Center. This form cannot be processed without the Plan Administrator, Trustee or Authorized Signer’s signature.

Be sure to keep a copy for your records.



By: Signature of Plan Administrator, Trustee or Authorized Signer			Date

Print Name of Plan Administrator, Trustee or Authorized Signer			Date

FOR PLAN ADMINISTRATOR USE ONLY - MAIL TO: 8488 Shepherd Farm Drive, West Chester, OH 45069,Fax #: (877) 449-4443

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How do I do a rollover?

There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover.

If you do a direct rollover, the Plan will make the payment directly to your IRA or an employer plan. You should contact the IRA sponsor or the administrator of the employer plan for information on how to do a direct rollover.

If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible employer plan that will accept it. You will have 60 days after you receive the payment to make the deposit. If you do not do a direct rollover, the Plan is required to withhold 20% of the payment for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll over the entire payment in a 60-day rollover, you must use other funds to make up for the 20% withheld. If you do not roll over the entire amount of the payment, the portion not rolled over will be taxed and will be subject to the 10% additional income tax on early distributions if you are under age 59 1/2 (unless an exception applies).

How much may I roll over?

If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except:

●Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

●Required minimum distributions after age 70 1/2 (or after death)

●Hardship distributions

●ESOP dividends

●Corrective distributions of contributions that exceed tax law limitations

●Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends)

●Cost of life insurance paid by the Plan

●Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment

●Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP (also, there will generally be adverse tax consequences if you roll over a distribution of S corporation stock to an IRA).

The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.

If I don't do a rollover, will I have to pay the 10% additional income tax on early distributions?

If you are under age 59 1/2, you will have to pay the 10% additional income tax on early distributions for any payment from the Plan (including amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed below applies. This tax is in addition to the regular income tax on the payment not rolled over.

The 10% additional income tax does not apply to the following payments from the Plan:

●Payments made after you separate from service if you will be at least age 55 in the year of the separation

●Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

●Payments from a governmental defined benefit pension plan made after you separate from service if you are a public safety employee and you are at least age 50 in the year of the separation

●Payments made due to disability

●Payments after your death

●Payments of ESOP dividends

●Corrective distributions of contributions that exceed tax law limitations

●Cost of life insurance paid by the Plan

●Payments made directly to the government to satisfy a federal tax levy

●Payments made under a qualified domestic relations order (QDRO)

●Payments up to the amount of your deductible medical expenses

●Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more than 179 days

●Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution.

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If you were born on or before January 1, 1936

If you were born on or before January 1, 1936, and receive a lump sum distribution (or you receive a distribution from a designated Roth account that is not a qualified distribution) that you do not roll over, special rules for calculating the amount of the tax on the earnings in the payment might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income.

If your payment is from a governmental section 457(b) plan

If the Plan is a governmental section 457(b) plan, the same rules described elsewhere in this notice generally apply, allowing you to roll over the payment to an IRA or an employer plan that accepts rollovers. One difference is that, if you do not do a rollover, you will not have to pay the 10% additional income tax on early distributions from the Plan even if you are under age 59 1/2 (unless the payment is from a separate account holding rollover contributions that were made to the Plan from a tax-qualified plan, a section 403(b) plan, or an IRA). However, if you do a rollover to an IRA or to an employer plan that is not a governmental section 457(b) plan, a later distribution made before age 59 1/2 will be subject to the 10% additional income tax on early distributions (unless an exception applies). Other differences are that you cannot do a rollover if the payment is due to an "unforeseeable emergency" and the special rules under "If your payment includes employer stock that you do not roll over" and "If you were born on or before January 1, 1936" do not apply.

If are an eligible retired public safety officer (and, for those who receive distributions from a designated Roth account, you receive a nonqualified distribution), and your pension payment is used to pay for health coverage or qualified long-term care insurance

If the Plan is a governmental plan, you retired as a public safety officer, and your retirement was by reason of disability or was after normal retirement age, you can exclude from your taxable income nonqualified distributions paid directly as premiums to an accident or health plan (or a qualified long-term care insurance contract) that your employer maintains for you, your spouse, or your dependents, up to a maximum of $3,000 annually. For this purpose, a public safety officer is a law enforcement officer, firefighter, chaplain, or member of a rescue squad or ambulance crew.

If you roll over your payment to a Roth IRA (applicable to payments that do NOT come from designated Roth accounts only)

You can roll over a payment from the Plan made before January 1, 2010 to a Roth IRA only if your modified adjusted gross income is not more than $100,000 for the year the payment is made to you and, if married, you file a joint return. These limitations do not apply to payments made to you from the Plan after 2009. If you wish to roll over the payment to a Roth IRA, but you are not eligible to do a rollover to a Roth IRA until after 2009, you can do a rollover to a traditional IRA and then, after 2009, elect to convert the traditional IRA into a Roth IRA.

If you roll over the payment to a Roth IRA, a special rule applies under which the amount of the payment rolled over (reduced by any after-tax amounts) will be taxed. However, the 10% additional income tax on early distributions will not apply (unless you take the amount rolled over out of the Roth IRA within 5 years, counting from January 1 of the year of the rollover). For payments from the Plan during 2010 that are rolled over to a Roth IRA, the taxable amount can be spread over a 2-year period starting in 2011.

If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified distributions will not be taxed (including earnings after the rollover). A qualified distribution from a Roth IRA is a payment made after you are age 59 1/2 (or after your death or disability, or as a qualified first-time homebuyer distribution of up to $10,000) and after you have had a Roth IRA for at least 5 years. In applying this 5-year rule, you count from January 1 of the year for which your first contribution was made to a Roth IRA. Payments from the Roth IRA that are not qualified distributions will be taxed to the extent of earnings after the rollover, including the 10% additional income tax on early distributions (unless an exception applies). You do not have to take required minimum distributions from a Roth IRA during your lifetime. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).

You may also roll over a payment from the Plan to a designated Roth account in an employer plan.

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WRITTEN EXPLANATION OF

QUALIFIED JOINT AND 50% CONTINGENT SURVIVOR ANNUITY FORM OF BENEFIT

This information only applies to retirement plans subject to the joint and survivor annuity requirements. To confirm if your plan is subject to these requirements, please refer to your Summary Plan Description or contact your Plan Administrator.

If, after receiving this Explanation, you elect an optional form of distribution and your spouse, if any, consents to that form, your distribution may be made less than 30 days from the date this Explanation was given to you. However, your distribution may not be made before the end of the seventh (7th) day after the date this Explanation was provided to you.

Terms and Conditions of the Form of Distribution

If your total vested benefit is:	Your general payment options are		Timing of your requested distribution:
	(referred to as “optional forms of
	benefit”):
$5,000 or less	•	Single Lump Sum	• As soon as administratively possible
More than $5,000	•	Single Lump Sum	• As soon as administratively possible
	•	Monthly Annuity	• Deferred to a later date (only if you are requesting a
	•	Installment Payments	distribution due to termination of employment)

A monthly annuity will be purchased from Transamerica Life Insurance Company or another insurance company with payments to commence on a date determined by you and the insurance company. Your benefit distribution, your age, your spouse’s age (if you are married), the survivor portion you elect for your spouse (if you are married), the number of guaranteed or installment payments you elect and the date distributions are to commence will determine the amount of your monthly annuity.

Following is a description of the optional forms of benefit generally available under the Plan:

	Form of benefit:	Available to Unmarried	Available to Married
		Participants	Participants
			Yes
	Single Lump Sum – a single cash payment	Yes	(requires spousal
			consent)
	Single Life Annuity – a life annuity, with monthly payments payable during your	Yes	Yes
	lifetime. Payments will stop at your death.	(automatic form of benefit)	(requires spousal
			consent)
	Life Annuity with payments for 60 months certain – a life annuity, with monthly		Yes
	payments payable during your lifetime but in no event payable for less than	Yes	(requires spousal
	60 months.		consent)
	Life Annuity with payments for 120 months certain – a life annuity, with monthly		Yes
	payments payable during your lifetime but in no event payable for less than	Yes	(requires spousal
	120 months.		consent)
	Life Annuity with payments for 180 months certain – a life annuity, with monthly		Yes
	payments payable during your lifetime but in no event payable for less than	Yes	(requires spousal
	180 months.		consent)
	Installment Payments – monthly payments for a period not exceeding the	Yes	Yes
			(requires spousal
	shorter of 15 years or your life expectancy.
			consent)
	Qualified Joint & 50% Contingent Survivor Annuity – monthly payments for
	your lifetime plus, after your death, if your spouse is still living, monthly		Yes
	payments to your spouse for his/her lifetime equal to 50% of the amount that	No	(automatic form of
	you received while you both were living. If your spouse pre-deceases you,		benefit)
	your monthly payments will not change. All payments will stop when both you
	and your spouse die.
	Qualified Joint & 100% Contingent Survivor Annuity – monthly payments for
	your lifetime plus, after your death, if your spouse is still living, the same
	amount of monthly payments to your spouse for his/her lifetime. If your	No	Yes
	spouse pre-deceases you, your monthly payments will not change. All
	payments will stop when both you and your spouse die.

In order to estimate the amount of the monthly annuity or installments that can be purchased by your requested distribution amount, please refer to the following attachments titled “How to Estimate Your Immediate Monthly Annuity or Installment Payment Worksheet” and “How to Estimate Your Deferred Monthly Annuity or Installment Payment Worksheet.” The monthly payments and installments calculated on the worksheets are only

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estimates. If you are considering a monthly annuity or installments and you want to know what the actual payment is under any optional form of benefit available to you, please contact your Plan Administrator.

Waiver of the Joint & 50% Contingent Survivor Annuity Form of Distribution

During the 180-day period ending on your annuity starting date (the first day of the first period for which an amount is payable as an annuity or, in the case of benefits not payable as an annuity, the first day on which all events have occurred which entitle you to benefits), you (with your spouse’s consent) may elect to waive (and therefore elect another form of payment) the Qualified Joint and 50% Contingent Survivor Annuity an unlimited number of times.

During the same 180-day period, you are permitted to revoke a previous waiver of the Qualified Joint and 50% Contingent Survivor Annuity an unlimited number of times.

Your election to waive the Qualified Joint and 50% Contingent Survivor Annuity will not be effective unless your spouse consents in writing to the waiver. The written consent must be made at the time of your waiver election and must acknowledge the effect of the election. In addition, your spouse’s written consent must be witnessed by a Plan Representative (who cannot be you) or a notary public. See Section J of the Distribution Request Form.

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EXAMPLE:	Suppose you are married and you and your spouse are both age 45 now.
	Also suppose your current vested account balance is $35,000. (Please contact your Plan Administrator if you need help determining your vested account balance.)
(a)		(b)	(c)	(d)
Optional Form of		Applicable APR factor from Step 2
Benefit		or Step 3	Applicable installment factor from Step 4	Amount of Immediate Distribution Equivalent to Vested Account Balance
Single Lump Sum		N/A	N/A	current vested account balance = $35,000
Single Life Annuity		264.75 (from Step 2)	N/A	$35,000 divided by col. (b) =	$132
Joint & 100%
Contingent Survivor
Annuity		292.25 (from Step 3 (i))	N/A	$35,000 divided by col. (b) =	$120
Joint & 50%
Contingent Survivor
Annuity		278.50 (from Step 3 (ii))	N/A	$35,000 divided by col. (b) =	$126
120 monthly
installments		N/A	104.02	$35,000 divided by col. (c) =	$336

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YOUR WORKSHEET (fill in the blanks):		Your current age:	_________
		Your current vested account balance:	$______________________
(a)	(b)	(c)	(d)
Optional Form of	Applicable APR factor from Step 2
Benefit	or Step 3	Applicable installment factor from Step 4	Amount of Immediate Distribution Equivalent to Vested Account Balance
Single Lump Sum	N/A	N/A	current vested account balance = $ ___________
Single Life Annuity	__ __ __.__ __ (from Step 2)	N/A	current vested account balance divided by col. (b) =	$ ______
Joint & 100%
Contingent Survivor
Annuity	__ __ __.__ __ (from Step 3(i))	N/A	current vested account balance divided by col. (b) =	$ ______
Joint & 50%
Contingent Survivor
Annuity	__ __ __.__ __ (from Step 3(ii))	N/A	current vested account balance divided by col. (b) =	$ ______
120 monthly
installments	N/A	104.02	current vested account balance divided by col. (c) =	$ ______

The APR and interest factors used in the above example and worksheet are only for estimating the monthly annuity that might be purchased from an insurance company and the installment payments. The actual amount of monthly annuity purchased from an insurance company and your installment payments may be higher or lower. Please contact your Plan Administrator before you make your benefit election if you are interested in the annuity or installment option. Your Plan Administrator will provide you with the actual amount of your monthly installment or annuity as obtained from an insurance company. Also, please contact your Plan Administrator if you would like information applicable to your individual situation, e.g. if you would like APR factors based on your spouse's actual age.

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Distribution Request Form - CSC

HOW TO ESTIMATE YOUR DEFERRED MONTHLY ANNUITY OR INSTALLMENT PAYMENT WORKSHEET

EXAMPLE:	Suppose you are married, you and your spouse are both age 45 now and you are deferring receipt of your distribution until age 65 (number of years you want to defer payment = 20).
	Also suppose your current vested account balance is $35,000. (Please contact your Plan Administrator if you need help determining your current vested account balance.)
(a)		(b)	(c)	(d)	(e)
		Applicable
		interest factor	Applicable APR factor from Step 3 or	Applicable installment
Optional Form of Benefit		from Step 1	Step 4	factor from Step 5	Amount of Deferred Distribution Equivalent to Current Vested Account Balance
Single Lump Sum		3.2071	N/A	N/A	$35,000 multiplied by col. (b) =	$112,249
Single Life Annuity		3.2071	171.66 (from Step 3)	N/A	$35,000 multiplied by col. (b) then divided by col. (c) =	$654
Joint & 100%
Contingent Survivor
Annuity		3.2071	206.77 (from Step 4(i))	N/A	$35,000 multiplied by col. (b) then divided by col. (c) =	$543
Joint & 50% Contingent
Survivor Annuity		3.2071	189.22 (from Step 4(ii))	N/A	$35,000 multiplied by col. (b) then divided by col. (c) =	$593
120 monthly
installments		3.2071	N/A	104.02	$35,000 multiplied by col. (b) then divided by col. (d) =	$1,079

January 2014

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Distribution Request Form - CSC

EXPLANATION OF PRE-RETIREMENT SURVIVOR ANNUITY

If you are married, the law provides (unless you elect otherwise) that the death benefits be paid to your spouse in the form of a Pre-Retirement Survivor Annuity. Under this Pre-Retirement Survivor Annuity, payments will be made each month for your spouse’s lifetime. Your spouse may have the option of electing a different form of payment prior to the date that benefits are scheduled to begin. A description of the amount and the eligibility requirements for this benefit is contained in the Summary Plan Description. If you do not have a copy of this informative booklet, you should request a copy from your Employer.

If you are not married, you can designate whomever you wish to be the beneficiary of this death benefit. If you get married, however, this designation will become invalid and your spouse will become the beneficiary unless you file a new beneficiary designation form approved by your spouse as described below.

You and your spouse can elect, at any time, not to be covered by the Pre-Retirement Survivor Annuity. That is, you can designate a person other than your spouse to be the beneficiary of your death benefit. This election will not be valid, however, without your spouse’s written consent. Your spouse’s written consent must either be witnessed by a Plan Representative or a Notary Public. In addition, if your election is made before you are age 35; the election becomes invalid on the first day of the Plan Year in which you reach age 35. If you and your spouse do not make a new election after you have attained age 35, your spouse will automatically become your beneficiary.

If you elect to waive the Pre-Retirement Survivor Annuity, such waiver will only apply to your spouse who consented to that waiver. If you later remarry (following a divorce or the death of your current spouse), your election will become invalid and your new spouse will be your beneficiary unless you make a new election consented by your new spouse.

If you elect not to be covered by the Pre-Retirement Survivor Annuity, you may later revoke the election. You do not need your spouse’s consent to do this. If you revoke your election, you will once again be covered by the Pre-Retirement Survivor Annuity and your spouse will be your beneficiary.

The examples below compare benefits under the qualified Pre-Retirement Survivor Annuity and other forms of distribution. The examples are based on specific assumptions and certain interest rates and mortality rates. The amounts shown are used to illustrate the differences between the various options. The values may be different in your case. Assume a participant dies at age 45 with a vested account balance of $35,000 and has a spouse of the same age.

	Benefit to Spouse
Type of Immediate Distribution	After Participant Dies
Single Lump Sum	$	35,000
Single Life Annuity	$	132 per month
120 Monthly Installments	$	336 per month

A monthly annuity will be purchased from Transamerica Life Insurance Company or another insurance company with payments to commence on a date determined by you and the insurance company. The amount of the monthly annuity depends upon the value of your vested account balance, your spouse’s age and the date distributions commence.

In order to estimate the amount of monthly annuity or installments that can be purchased by your vested account balance on your spouse’s behalf, please refer to the attachment titled “Qualified Pre-Retirement Survivor Annuity or Installment Payment Worksheet”. The monthly annuity and installments calculated on the worksheet are only estimates. If you are considering retaining the Pre-Retirement Survivor Annuity or if your spouse is considering electing installment payments in place of the Pre-Retirement Survivor Annuity, and you want to know what the actual payment would be, please contact your Plan Administrator.

It is important that you and your spouse understand your rights and obligations concerning your death benefit. Please contact your Plan Administrator if you have any questions. Also, because a spouse has certain rights to the death benefit, you should immediately inform your Plan Administrator of any change in your marital status.

January 2014

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Distribution Request Form - CSC

QUALIFIED PRE-RETIREMENT SURVIVOR ANNUITY OR INSTALLMENT PAYMENT WORKSHEET

EXAMPLE:	Suppose you are married and you and your spouse are both age 45 now.
	Also suppose your current vested account balance is $35,000.
	(Please contact your Plan Administrator if you need help determining your vested account balance.)
(a)	(b)	(c)	(d)
	Applicable APR factor from		Amount of Immediate Distribution Equivalent to Vested Account
Optional Form of Benefit	Step 2	Applicable installment factor from Step 3	Balance
Single Lump Sum	N/A	N/A	current vested account balance = $35,000
Single Life Annuity	264.75	N/A	$35,000 divided by col. (b) =	$132

YOUR WORKSHEET (fill in the blanks):		Your spouse's current age:	_________
		Your current vested account balance:	$______________________
(a)	(b)	(c)	(d)
	Applicable APR factor from		Amount of Immediate Distribution Equivalent to Vested Account
Optional Form of Benefit	Step 2	Applicable installment factor from Step 3	Balance
Single Lump Sum	N/A	N/A	current vested account balance = $ ___________
Single Life Annuity	__ __ __.__ __ (from Step 2)	N/A	current vested account balance divided by col. (b) = $ ______

The APR and interest factors used in the above example and worksheet are only for estimating the monthly annuity that might be purchased from an insurance company and the installment payments. The actual amount of monthly annuity purchased from an insurance company and installment payments may be higher or lower. Please contact your Plan Administrator for the actual amount that

may be paid to your spouse in annuity or installment forms of benefit. Also, please contact Plan Administrator if you need information applicable to your individual situation, e.g. if your spouse's current age is not shown on the attached Annuity Purchase Rate Table.

January 2014

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Distribution Request Form - CSC

QPSA ADDITIONAL INFORMATION

With the attached worksheet and the enclosed tables, you and your spouse should be able to compare the financial effect of electing different optional forms of benefit generally available under the Plan. If you would like to be provided with the financial effect of any other optional form of benefit available to you under the Plan, please contact your Plan Administrator.

The APR and interest factors used in this example and worksheet are only for estimating the monthly annuity that might be purchased from an insurance company and the installment payments. The actual amount of monthly annuity purchased from an insurance company and your spouse's installment payments may be higher or lower. Please contact your Plan Administrator for the actual amount that may be paid

to your spouse in the annuity or installment forms of benefit.

In addition, if the current age of your spouse is not shown on the enclosed annuity factor table, please contact your Plan Administrator and the appropriate annuity factors will be provided for your individual situation.

If you and your spouse have any questions regarding your specific situation or if you need help in completing this worksheet, please contact your Plan Administrator. Please note that this worksheet is based on certain interest and mortality assumptions which may not apply to your specific situation.

January 2014

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Distribution Request Form - CSC

			ANNUITY PURCHASE RATES						ANNUITY PURCHASE RATE
			TO BE USED TO ESTIMATE YOUR MONTHLY ANNUITY						TO BE USED TO ESTIMATE
								YOUR INSTALLMENT PAYMENTS
(The following rates are based on an assumed interest rate of 3% per year and the 1983 GAM Male Mortality Table, projected to 2007 with Scale H, 1 year								(The following rate is based on an assumed
		setback for Participant, 1 year setback for Contingent Annuitant)							interest rate of 3% per year)
	Single	Joint & 100%	Joint & 50%		Single	Joint & 100%	Joint & 50%		10-Year
Your	Life	Contingent	Contingent	Your	Life	Contingent	Contingent	Your	Monthly
Age	Annuity	Survivor Annuity	Survivor Annuity	Age	Annuity	Survivor Annuity	Survivor Annuity	Age	Installment
25	325.33	342.84	334.09	53	231.25	262.81	247.03	Any age	104.02
26	323.04	340.94	331.99	54	226.71	258.70	242.71
27	320.69	338.99	329.84	55	222.10	254.49	238.30
28	318.27	336.98	327.63	56	217.42	250.19	233.80
29	315.78	334.92	325.35	57	212.66	245.78	229.22
30	313.22	332.79	323.01	58	207.81	241.26	224.54
31	310.59	330.60	320.60	59	202.88	236.64	219.76
32	307.88	328.35	318.11	60	197.87	231.92	214.89
33	305.09	326..03	315.56	61	192.77	227.09	209.93
34	302.23	323.64	312.93	62	187.58	222.15	204.87
35	299.28	321.17	310.23	63	182.33	217.12	199.72
36	296.24	318.64	307.44	64	177.02	211.99	194.50
37	293.11	316.03	304.57	65	171.66	206.77	189.22
38	289.88	313.35	301.61	66	166.28	201.47	183.87
39	286.55	310.58	298.57	67	160.87	196.09	178.48
40	283.14	307.74	295.44	68	155.47	190.66	173.07
41	279.64	304.81	292.22	69	150.09	185.18	167.63
42	276.05	301.80	288.92	70	144.75	179.66	162.20
43	272.37	298.70	285.53	71	139.46	174.11	156.79
44	268.60	295.52	282.06	72	134.22	168.55	151.39
45	264.75	292.25	278.50	73	129.04	162.96	146.00
46	260.83	288.89	274.86	74	123.91	157.37	140.64
47	256.82	285.44	271.13	75	118.80	151.75	135.27
48	252.75	281.90	267.33	76	113.73	146.12	129.92
49	248.60	278.27	263.44	77	108.72	140.49	124.60
50	244.38	274.55	259.46	78	103.77	134.89	119.33
51	240.08	270.73	255.41	79	98.92	129.32	114.12
52	235.70	266.82	251.26	80	94.16	123.81	108.98

Actuarial Assumptions:

Assumed Interest Rate: 3% per year

Mortality Table: 1983 GAM-Male projected to 2007 using Scale H, (-1,-1)

Spouse assumed to be the same age as the participant

NOTE: The above Assumed Interest Rate and Mortality Table are representative of the interest rate and mortality table used to purchase an annuity from Transamerica Life Insurance Company for calendar year 2007.

January 2014

Page 27 of 28

Distribution Request Form - CSC