Incoming Contract Exchange/direct Rollover (Page 2 of 4) in pdf

95803-01

Last Name

First Name

M.I.

Social Security Number

Number

Previous Provider must complete for contract exchanges and direct rollovers from previous plans:

12/31/86 values: $

For 403(b)(1) plans only - 12/31/88 values: $

If no historical account value information is provided within 60 days of Service Provider's receipt of the funds, I understand that Service Provider will

treat the entire exchanged amount as attributable to post-December 31, 1988 values.

Previous Plan Administrator must provide the following information for Designated Roth Account Rollovers:

Roth first contribution date:

Roth contributions (no earnings): $

Amount of Contract Exchange/Direct Rollover: $

(Enter approximate amount if exact amount is not known.)

Investment Option Information -

Please refer to your communication materials for investment option designations.

I understand that 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.

Select either existing ongoing allocations (A) or your own investment options (B).

(A) Existing Ongoing Allocations

I wish to allocate this exchange/rollover the same as my existing ongoing allocations.

(B) Select Your Own Investment Options

Please Note: For automatic dollar cost averaging call the Voice Response System or access our Web site.

INVESTMENT OPTION

NAME

TICKER CODE

NAME

TICKER CODE

Alliance Development Fund. . . . . . . . . . . . . . . . . . . . . N/A

CMAADF _____

TIAA-CREF Lifecycle Index Ret Inc Inst. . . . . . . TRILX

TRILX

_____

Prudential High-Yield Q. . . . . . . . . . . . . . . . . . . . . . . . . PHYQX

PHYQX

_____

TIAA-CREF Lifecycle Index 2060 Instl. . . . . . . . . TVIIX

TVIIX

_____

Prudential Total Return Bond Z. . . . . . . . . . . . . . . . . PDBZX

PDBZX

_____

TIAA-CREF Lifecycle Index 2055 Instl. . . . . . . . . TTIIX

TTIIX

_____

Templeton Global Bond R6. . . . . . . . . . . . . . . . . . . . . . FBNRX

FBNRX

_____

TIAA-CREF Lifecycle Index 2050 Instl. . . . . . . . . TLLIX

TLLIX

_____

American Century Growth R6. . . . . . . . . . . . . . . . . . . AGRDX

AGRDX

_____

TIAA-CREF Lifecycle Index 2045 Instl. . . . . . . . . TLXIX

TLXIX

_____

Invesco Growth and Income R6. . . . . . . . . . . . . . . . . GIFFX

GIFFX

_____

TIAA-CREF Lifecycle Index 2040 Instl. . . . . . . . . TLZIX

TLZIX

_____

Steward Large Cap Enhanced Index Inst. . . . . . . . SEECX

SEECX

_____

TIAA-CREF Lifecycle Index 2035 Instl. . . . . . . . . TLYIX

TLYIX

_____

Vanguard 500 Index Admiral. . . . . . . . . . . . . . . . . . . . VFIAX

VFIAX

_____

TIAA-CREF Lifecycle Index 2030 Instl. . . . . . . . . TLHIX

TLHIX

_____

ASTON/Fairpoint Mid Cap I. . . . . . . . . . . . . . . . . . . . ABMIX

ABMIX

_____

TIAA-CREF Lifecycle Index 2025 Instl. . . . . . . . . TLQIX

TLQIX

_____

JPMorgan Mid Cap Value Instl. . . . . . . . . . . . . . . . . . FLMVX

FLMVX

_____

TIAA-CREF Lifecycle Index 2020 Instl. . . . . . . . . TLWIX

TLWIX

_____

Columbia Small Cap Value Fund II R5. . . . . . . . . . CRRRX

CRRRX

_____

TIAA-CREF Lifecycle Index 2015 Instl. . . . . . . . . TLFIX

TLFIX

_____

Cohen & Steers Instl Realty Shares. . . . . . . . . . . . . . CSRIX

CSRIX

_____

TIAA-CREF Lifecycle Index 2010 Instl. . . . . . . . . TLTIX

TLTIX

_____

Prudential Jennison Natural Resources Q. . . . . . . . PJNQX

PJNQX

_____

Principal SmallCap Growth I Instl. . . . . . . . . . . . . . . PGRTX

PGRTX

_____

American Funds EuroPacific Gr R6. . . . . . . . . . . . . RERGX

RERGX

_____

Steward Small-Mid Cap Enhanced Idx Inst. . . . . . SCECX

SCECX

_____

Oppenheimer Developing Markets I. . . . . . . . . . . . . ODVIX

ODVIX

_____

MUST INDICATE WHOLE PERCENTAGES

= 100%

Participant Acknowledgements

General Information - I understand that only certain types of distributions are eligible for contract exchange/rollover treatment and that it is solely my

responsibility to ensure such eligibility. By signing below, I affirm that the funds I am exchanging/rolling are in fact eligible for such treatment.

I authorize these funds to be transferred into my employer's Plan 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 Service Provider to allocate the contract exchange/direct rollover assets

("assets") the same as my ongoing contributions (if I have an account established) or to the default investment option selected by my Plan (if I do not

have an account established). If no default investment option is selected, the funds will be returned to the payor as required by law. If my assets are

received more than 180 calendar days after Service Provider receives this Incoming Contract Exchange/Direct Rollover form (this "form"), I authorize

Service Provider to allocate all monies received the same as my ongoing allocation election on file with Service Provider. I understand I must call the

Voice Response System or access the Web site in order to make changes or transfer monies from the default investment option. The assets will be

processed on the day this form is received. I understand that this completed form must be received by Service Provider 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

Custodian/Provider may wish to obtain in order to effect the transaction.

Withdrawal Restrictions - I understand that the Internal Revenue Code and/or my employer's Plan Document may impose restrictions on the

availability of certain monies (amounts contributed and accruing after December 31, 1988) under 403(b) tax sheltered annuities. The restricted monies

cannot be distributed to participants before the occurrence of one of the following: attainment of age 59½; severance of employment from the employer

(due to total disability, retirement, termination or otherwise); financial hardship as defined under present or future IRS regulations (in which case only

elective deferrals may be withdrawn); or death of participant.

Investment Options - I understand that by signing and submitting this form for processing, I am requesting to have investment options and/or variable

annuity funding accounts established under the Plan as specified in the Investment Option Information section. I understand and agree that this account(s)

NO_GRPG 41268/

YSAL

][

GWRS FRLCNT

06/03/16

95803-01

CHG NUPART

DOC ID: 435521698

)

][

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Page 2 of 4

Incoming Contract Exchange/direct Rollover Page 2

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