Fillable Asset Transfer Request Form (Page 2 of 3) in pdf

5. Asset transfer information

(Select either direct rollover, contract exchange, plan to plan transfer or transfer. If you select direct rollover, check all that apply in

section 5a. If you select either contract exchange, plan to plan transfer or transfer, indicate an amount in section 5b.)

Direct rollover (Employer and/or market has changed). (If you are rolling over employer accounts, no IRS qualifying event is required,

refer to employer for eligibility.)

Under IRS regulations, a participant is only eligible to roll over employee deferrals and earnings for one of the reasons listed below.

5a. Rollover eligibility, please check all that apply:

Age 59 ½ or older

Death

Qualified Domestic Relations Order (QDRO)

In-service distribution of a Governmental 457(b) plan of $5,000 or less

Severance from employment

Total and permanent disability

Withdrawal of pre-1989 grandfathered value from a 403(b) plan

Note: Required minimum distributions, hardship withdrawals, substantially equal periodic payments and excess contributions are not

eligible for rollover.

Contract exchange (403(b) to 403(b) only - Transfer from one contract to another within the same employer’s plan and market is not

changing)

A participant may request a contract exchange of his/her account with the same employer to a different funding vehicle without meeting a

distribution event. However, based on the final 403(b) regulations, the funding vehicle must be approved by the plan administrator and an

Information Sharing Agreement must be in place with the recipient vendor.

Plan to plan transfer (403(b) to 403(b) only - Transfer from one contract to another, but employee has changed employers and/or employers

are related per plan documents)

A participant, who has a distribution event, may request a plan to plan transfer of his/her account to the new employer’s plan. Both the

prior employer and new employer must agree to this transfer.

Transfer (All markets except 403(b) plans - Transfer from one contract to another within the same employer’s plan and market is not

changing)

5b. Indicate the amount of the contract exchange, plan to plan transfer, or transfer:

Employee elective deferral

$ _________________

Employer matching contribution

$ ___________________

Roth

$ _________________

Employer discretionary contribution $ ___________________

Other: _______________________________________

$__________________

6. Agreement and signatures

Beginning September 25, 2007, final 403(b) regulations began imposing new rules for contract exchanges.

A contract exchange processed on or after that date may require that the employer enter into an Information Sharing Agreement by January 1,

2009, or agree to coordinate the information necessary to satisfy Section 403(b) before any future distribution or loan is made from the recipient

investment/contract provider.

If your employer is not currently sending contributions to Lincoln, or if an Information Sharing Agreement is not currently in place, then Lincoln

agrees to make a reasonable, good faith effort to contact the employer as required under Revenue Procedure 2007-71 before processing future

distributions or loans.

Beginning January 1, 2009, Lincoln will not accept a contract exchange unless a completed Information Sharing Agreement, or equivalent, has

been received.

The issuer and participant agree as follows:

• You recognize that by implementing this asset transfer, the participant’s contract may be subject to the same or more stringent restrictions

on distributions.

• Lincoln can only accept checks or money orders.

• The check or money order must be issued directly to The Lincoln National Life Insurance Company in payment of the designated value for

the asset transfer from this account. Lincoln hereby accepts the asset transfer of assets requested above.

Checks should be mailed to:

The Lincoln National Life Insurance Company

PO Box 2212

1300 South Clinton Street

Fort Wayne, IN 46801-2212

• Transfers in-kind are not acceptable. (Securities should be liquidated, redeemed or sold.)

• You verified direct rollovers are allowed with your plan administrator and this amount is permitted to be rolled over.

• You relied on advice received from your tax advisor relating to federal and state income tax questions associated with this asset transfer and

not upon any information furnished or representations made by Lincoln, its agents or employees.

Michele Booth, Vice President

If you want the asset transfer deposited differently than the investment elections already on file, you must complete the Lincoln

Contract Information on the last page.

Participant’s signature ________________________________________________________________ ___ Date ________/_______/_____________

Plan administrator’s signature ____________________________________________________________ Date ________/_______/_____________

(may be required by recipient vendor)

If you have any questions, please contact a customer service representative at 1-800-454-6265.

PAD-1174423-041515

Page 2 of 3

RPS22135-MF9

05/15

Asset Transfer Request Form Page 2

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