The Directed Account Plan Partial Withdrawal Request Form (Page 2 of 3) in pdf

The amount of your withdrawal will be pro-rated across all available investment options in your account. If you would like the funds to

be withdrawn from a specific investment option(s), please indicate from which funds you’d like the withdrawal to be taken. The dollar

amounts below must equal your total withdrawal request.

Conservative Model $_________ Moderate Model $__________ Aggressive Model $__________ Retirement Model $__________

Stable Value Option $__________ Value Stock Option $__________ Equity Index Option $__________

Growth Stock Option $__________ International Stock Option $__________

Diversified Small Co. Option $__________

Fidelity Funds (List Name of fund and dollar amount): ________________________________________________________________

WITHHOLDING TAX NOTICE

Please review carefully since taxes withheld are remitted to the Internal Revenue Service as soon as a distribution occurs and cannot

be returned.

I understand that all or a portion of the distribution which I do not elect to have transferred as a direct rollover to either an Individual

Retirement Account (IRA) or to another qualified retirement plan will be subject to mandatory withholdings of federal income tax. 20% of

the taxable portion of my distribution which is not transferred will be withheld and remitted to the Internal Revenue Service. Depending

upon my tax status, I may owe additional taxes on this distribution.

I understand that I may defer my distribution at least thirty (30) days after receipt of the Notice of Taxation. I hereby elect

a distribution or direct rollover seven (7) days after the explanation of the joint and survivor annuity has been provided to me and if I

have obtained the consent of my spouse, where applicable.

I understand that my distribution may also be subject to state income tax and that I may elect not to have state income withholding

apply to my withdrawal. If I do not elect to have state income taxes withheld, I may be responsible for payment of an estimated state

income tax.

A portion of this distribution may also be subject to the 10% penalty tax under the Internal Revenue Code for the early withdrawals.

This penalty tax is in addition to federal and state income taxes.

I DO NOT elect to transfer all or a portion of my distribution in a direct rollover to an IRA or to another qualified plan.

want state tax withheld from my distribution. Please note: In some states, tax withholding is mandatory.

I DO

DO NOT

State taxes withheld follow state guidelines: straight percent of withdrawal, or percentage of federal tax amount.

Note: Not withstanding the above election, state income tax will be withheld if required.

Any exchanges or withdrawals made within your account after the time you requested this transaction and before actual

processing may cause your transaction to be rejected.

I have read and understand the provisions of full distributions. I further understand the tax implications. I hereby authorize the company

to distribute to me the amount indicated above as a full distribution. I understand that an incomplete withdrawal application will be

returned to me.

Fidelity Investments Institutional Operations Company, Inc.

549806.2.0

The Directed Account Plan Partial Withdrawal Request Form Page 2