Form Std Fspsrv - Separation From Employment Withdrawal Request 401(A) Plan (Page 9 of 14) in pdf

Interest Only Payments

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This option is only available to me if I have at least one fixed investment option.

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My payment will vary depending on the type and performance of the fixed investment options.

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My payment will continue until I reach age 70½, at which point my periodic installment payment option will be automatically converted to my required

minimum distribution and withdrawals will be made at the same frequency as my interest only payments.

Section D: To whom do I want my withdrawal payable and where should it be sent?

It is my responsibility to make sure that the Trustee/Custodian/Provider information provided is accurate.

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Service Provider is not responsible for misdirected payments due to incorrect information or address.

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Section E: How do I want my withdrawal delivered?

Certain delivery options are not available on all types of withdrawals.

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Delivery of payment is based on completion of the withdrawal process, which includes receipt of a complete request in good order.

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I must select a delivery option from the choices provided. If I do not make any selection, all transactions will be sent by United States Postal Service

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(“USPS”) regular mail.

Below is a description of each delivery option.

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Check by USPS Regular Mail

Estimated delivery time is 7-10 business days

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No additional charge

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If the check is payable to me, it will be sent to the address on file unless an address change or alternate address is indicated in the 'Signatures and

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Consent' section of the form and is properly notarized or witnessed.

If the check is payable to another retirement provider, it will be sent to the address indicated in Section D.

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Check by Express Delivery

Estimated delivery time is 1-2 business days

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A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction.

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For example, if I elected to make a full withdrawal with a portion payable to me and the remainder rolled over to an eligible plan, and I have after-

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tax money sources, there will be 3 different transactions and I may be charged up to a total of $75.00 for the Express delivery fees.

Not available for Periodic Installment Payments

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Available for delivery, Monday-Friday, with no signature required upon delivery

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If the check is payable to me, it will be sent to the address on file unless an address change or alternate address is indicated in the 'Signatures and

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Consent' section and is properly notarized or witnessed.

If the check is payable to another retirement provider, it will be sent to the address indicated in Section D.

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If the address is a P.O. Box, the check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.

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Delivery is not guaranteed to all areas

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Direct Deposit via Automated Clearing House ("ACH")

I would elect this option if I want my payment to be electronically deposited into my personal checking or savings account.

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Estimated delivery time is 2-3 business days

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A non-refundable charge of up to $15.00 will be deducted, in addition to any withdrawal fees, for each transaction.

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Not available for Direct Rollovers

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Available for Periodic Installment Payments at no charge

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If I have requested a periodic installment payment and my first payment processing date does not allow for the 10 day pre-notification process, I

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understand that my first payment will be sent by check to my address on file.

The name on my checking/savings account MUST match the name on file with Service Provider.

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For deposit into my checking account, I MUST attach a copy of a preprinted voided check for the receiving account. I may also attach a letter

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on financial institution letterhead, signed by a representative from the receiving institution, which indicates my name, checking account number and

the ABA routing number.

For deposit into my savings account, I MUST attach a letter on financial institution letterhead, signed by a representative from the receiving

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institution, which indicates my name, savings account number and the ABA routing number.

An ACH request can not be sent to a prepaid debit card, an IRA, or a business account.

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Any missing, incomplete, or inaccurate information will delay my withdrawal request.

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ACH credit can only be made into a United States financial institution.

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Any requests received referencing a foreign financial institution or referencing a United States financial institution with a further credit to an account

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associated with a foreign financial institution will be rejected.

General ACH Information

I authorize Service Provider to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error.

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In addition, I authorize my financial institution, in the form of an electronic funds transfer, to credit and/or debit the same to such account.

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Service Provider will make payment in accordance with the direction I have specified on this Withdrawal Form until such time that I notify

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Service Provider in writing that I wish to cancel the ACH agreement.

I must provide notice of cancellation at least 30 days prior to a payment date for the cancellation to be effective with respect to all of my subsequent

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payments.

Service Provider reserves the right to terminate the ACH transfers for any reason and will notify me in the event of such termination by sending

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notice to my last known address on file with Service Provider.

It is my obligation to notify Service Provider of any address or other changes affecting electronic fund transfers during my lifetime.

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I am solely responsible for any consequences and/or liabilities that may arise out of my failure to provide such notification.

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By selecting the ACH method of delivery, I acknowledge that Service Provider is not liable for payments made by Service Provider in accordance

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with a properly completed Withdrawal Form.

I am authorizing and directing my financial institution not to hold any overpayments made by Service Provider on my behalf, or on behalf of my

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estate or any current or future joint account holder, if applicable.

ACH delivery is not available to a foreign financial institution or to a United States financial institution for subsequent transfer to a foreign financial

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institution.

Any requests received containing foreign financial institution instructions will be rejected and require new ACH or check delivery instructions.

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STD FSPSRV

07/31/17