Form 5304-Simple - Savings Incentive Match Plan For Employees Of Small Employers (Simple) - Not For Use With A Designated Financial Institution Page 3

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Form 5304-SIMPLE (Rev. 3-2012)

Page

Model Notification to Eligible Employees

Opportunity to Participate in the SIMPLE IRA Plan

You are eligible to make salary reduction contributions to the

SIMPLE IRA

plan. This notice and the attached summary description provide you with information that you should consider before you decide whether to

start, continue, or change your salary reduction agreement.

II.

Employer Contribution Election

For the

calendar year, the Employer elects to contribute to your SIMPLE IRA (employer must select either (1), (2), or (3)):

(1) A matching contribution equal to your salary reduction contributions up to a limit of 3% of your compensation for the year;

(2) A matching contribution equal to your salary reduction contributions up to a limit of

% (employer must insert a

number from 1 to 3 and is subject to certain restrictions) of your compensation for the year; or

(3) A nonelective contribution equal to 2% of your compensation for the year (limited to compensation of $250,000*) if you are an

employee who makes at least $

(employer must insert an amount that is $5,000 or less) in compensation for

the year.

III.

Administrative Procedures

To start or change your salary reduction contributions, you must complete the salary reduction agreement and return it to

(employer should designate a place or

individual by

(employer should insert a date that is not less than 60 days after notice is given).

IV.

Employee Selection of Financial Institution

You must select the financial institution that will serve as the trustee, custodian, or issuer of your SIMPLE IRA and notify your Employer of

your selection.

Model Salary Reduction Agreement

Salary Reduction Election

Subject to the requirements of the SIMPLE IRA plan of

(name of

employer) I authorize

% or $

(which equals

% of my current rate of pay) to be withheld from

my pay for each pay period and contributed to my SIMPLE IRA as a salary reduction contribution.

II.

Maximum Salary Reduction

I understand that the total amount of my salary reduction contributions in any calendar year cannot exceed the applicable amount for that

year. See instructions.

III.

Date Salary Reduction Begins

I understand that my salary reduction contributions will start as soon as permitted under the SIMPLE IRA plan and as soon as

administratively feasible or, if later,

. (Fill in the date you want the salary reduction contributions to begin.

The date must be after you sign this agreement.)

IV.

Employee Selection of Financial Institution

I select the following financial institution to serve as the trustee, custodian, or issuer of my SIMPLE IRA.

Name of financial institution

Address of financial institution

SIMPLE IRA account name and number

I understand that I must establish a SIMPLE IRA to receive any contributions made on my behalf under this SIMPLE IRA plan. If the

information regarding my SIMPLE IRA is incomplete when I first submit my salary reduction agreement, I realize that it must be completed by

the date contributions must be made under the SIMPLE IRA plan. If I fail to update my agreement to provide this information by that date, I

understand that my Employer may select a financial institution for my SIMPLE IRA.

Duration of Election

This salary reduction agreement replaces any earlier agreement and will remain in effect as long as I remain an eligible employee under the

SIMPLE IRA plan or until I provide my Employer with a request to end my salary reduction contributions or provide a new salary reduction

agreement as permitted under this SIMPLE IRA plan.

Signature of employee

Date

This is the amount for 2012. For later years, the limit may be increased for cost-of-living adjustments. The IRS announces the increase, if any, in a news release, in the

Internal Revenue Bulletin, and on the IRS website at IRS.gov.

5304-SIMPLE

Form

(Rev. 3-2012)