Form 403(B)(7) - Erisa Retirement Plan Template (Page 2 of 2) in pdf

3. Waiver of Qualified Joint and Survivor Annuity

Your Retirement Plan Account is required to be distributed in the form of a qualified joint and survivor annuity (as described below) unless you waive

this form of benefit with the consent of your spouse. To receive your requested withdrawal amount, you must waive the qualified joint and survivor

annuity by completing this section. Your spouse (if any) must consent to your waiver and your spouse's consent must be witnessed by a notary

public or plan representative.

Required Certification To Be Completed By Non-Married Employee.

I hereby represent and certify that I am not married.

Election To Waive Qualified Joint and Survivor Annuity

I hereby elect to waive the payment of my withdrawal under the Retirement Plan in the form of a qualified joint and survivor annuity.

Required Spousal Consent To Be Completed By Spouse of Married Employee

I am legally married to the employee identified in Section 1. I have read and I understand the Notice of Joint and Survivor Annuity Rights as

provided by law, and I hereby consent to the election by my spouse to (1) waive the payment of his or her benefits in the form of a qualified joint

and survivor annuity, and (2) to receive the payment of his or her benefits in the form designated in Section 2, entitled "Withdrawal Method." I hereby

acknowledge that by signing this consent, and for as long as the election remains in effect, I am releasing and relinquishing my right to have my

spouse's withdrawal from the Retirement Plan Account paid in the form of a qualified joint and survivor annuity. My consent applies, however, only to

the specific withdrawal amount requested by my spouse on this form.

Spouse's Signature

The foregoing "Spousal Consent" was witnessed by me this _________ day of __________________ , (year) ________ .

Witness (Plan Representative or Notary Public):

Title:

Note: Please read the bottom of form for additional information.

4. Income Tax Withholding

This section does not apply to installments. See Installment Payment Request Form.

If you elect to have your entire eligible rollover distribution transferred in a direct rollover to an IRA or a qualified plan, no federal tax will be withheld.

If you elect to have all or a portion of your eligible rollover distribution paid to you, the signer understands that a 20% federal tax will be withheld on

the taxable portion of the distribution. In addition, state tax will be withheld according to your state's guidelines. If you reside in a state which gives

you the option not to withhold or to determine a dollar amount or percentage you want to withhold, please indicate below.

Withhold state taxes.

Where applicable, indicate specific dollars $ ____________ or percentage _______%.

Do not withhold state taxes.

5. Authorization

I hereby acknowedge that I have received and read the "Special Tax Notice Regarding Plan Payments" and realize that 20% of my distribution will

be withheld if it is not transferred in a direct rollover.

Signature of Employee

Date

Signature of Employer

Date

Termination Date

Supp.

(mm/dd/yyyy)

EE Basic

ER Basic

Eligible Sources:

_____ / _____ / _____

Vested Percentage (if applicable) __________ %

After-Tax Balance

All or a portion of your after-tax balance in your 403(b)7 plan is eligible to be rolled over to a traditional IRA or another 403(b) plan, subject to the

receiving plans provisions. You also may elect to have all or a portion of the after-tax balance mailed directly to you.

Withdrawal Method: Forms of Distribution

Lump Sum Cash - By selecting this option you will receive your entire eligible cash balance.

Installments - By selecting this option you will receive a series of payments over a period of time.

Partial Distribution - By selecting this option you will receive a one-time partial payment from your retirement account.

Direct Rollover to Vanguard traditional IRA - By selecting this option you may choose to have all or a portion of your eligible balance rolled over to

a Vanguard traditional IRA. If you wish to receive any portion in cash, please check off the Partial Distribution box under Withdrawal Method and

indicate the amount. If you do not currently have a Vanguard IRA, you will need to complete a Vanguard IRA Adoption Agreement.

Other Eligible Retirement Plan or Non-Vanguard IRA - By selecting this option you may have all or a portion of your eligible cash balance rolled

over to a traditional IRA or other eligible employer plan as described in the accompanying Special Tax Notice Regarding Plan Payments. In addition,

it is your responsibility to open an account at the receiving institution prior to initiating your direct rollover through Vanguard.

Vanguard 403(b)(7) Custodial Account

Notice of Joint and Survivor Annuity Rights

By law, your Retirement Plan Account may be required to be distributed in the form of a qualified joint and survivor annuity, unless you (and your

spouse, if married) waive this form of benefit. The Employee Retirement Income Security Act (ERISA) mandates that if you do not waive your right to

a qualified joint and survivor annuity, your distribution must be used to purchase an annuity contract. Furthermore, if you are married, your qualified

joint and survivor annuity contract must provide you with regular payments for the rest of your life and, if your spouse survives you, your spouse must

receive not less than 50 percent of the payments you were receiving for the rest of his or her life. If you are not married, the annuity contract must

provide you with regular payments for the rest of your life, with no survivor benefits payable upon your death.

If you do not wish to receive your Retirement Plan Account in the form of a qualified joint and survivor annuity (as described above), you may elect to

waive this form of benefit by completing the Waiver of Qualified Joint and Survivor Annuity in Section 3 of this form. If you are married, your spouse

must consent to your election to waive the qualified joint and survivor annuity, and your spouse's consent must be witnessed by a notary public or plan

representative. You may revoke any prior election to waive the qualified joint and survivor annuity form of benefit at any time prior to the distribution of

your account.

Form 403(B)(7) - Erisa Retirement Plan Template Page 2

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