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

Incoming Contract Exchange/direct Rollover Page 4

95803-01

Last Name

First Name

M.I.

Social Security Number

Number

Authorized Plan Administrator Approval

I acknowledge and agree that the Plan Administrator for the Previous Employer's Plan is released from and the Plan Administrator for the Current

Employer's Plan shall assume all obligations associated with any amounts transferred under this Incoming Contract Exchange/Direct Rollover form.

The Plan accepts the participant's direct rollover contribution from the prior employer's plan and has determined the funds are eligible for direct rollover.

If applicable, the Plan authorizes this participant's contract exchange from the provider under this plan listed in the Previous Provider section of this

form and has determined that funds are eligible for an exchange into this contract.

Authorized Plan Administrator Signature

Date

for Current Employer's Plan

Authorized Plan Administrator Signature

Date

for Previous Employer's Plan

(for direct rollovers)

Plan Administrator forward or fax as shown above

in the Payment Instructions section

Core securities, when offered, are offered through GWFS Equities, Inc. and/or other broker dealers.

GWFS Equities, Inc., Member FINRA/SIPC, is a wholly owned subsidiary of Great-West Life & Annuity Insurance Company.