Vanguard Section 403(B)(7) Plan Template (Page 2 of 3) in pdf

3. Waiver of Qualified Joint and Survivor Annuity

By law, your Vanguard 403(b)(7) Custodial Account must be distributed in the form of a qualified joint and survivor annuity (as described on the back of this form)

unless you waive this form of benefit with the consent of your spouse. To receive your requested withdrawal amount in a lump-sum or partial payment, 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 Vanguard Section 403(b)(7) Custodial Account 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 on the back of this form, 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 Vanguard Section 403(b)(7) Custodial 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.

(Name of beneficiary or beneficiaries designated under Vanguard 403(b)(7) Custodial Account

Spouse's Signature

The foregoing "Spousal Consent" was witnessed by me this ____day of_______________ , 20 ________.

Witness (Plan Representative or Notary Public): _______________________________________ Title: _______________________

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 403(b) plan, no Federal tax

will be withheld.

If you elect to have all or a portion of your eligible rollover distribution paid to you, you understand 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 understand and acknowledge 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

Title

Date