Clark-Pleasant Community School Corporation 401(a) and 403(b) Retirement Plan Distribution Form

Step 1: Participant Information (please print clearly) Participant’s Name

Soc Sec No Date of Birth

Street Address, Apt. # or Box #

City, State, Zip Code

Marital Status � Single � Married � Widowed � Divorced – Date Divorce Effective _________________________ Email Address

Daytime Phone Evening Phone

Step 2: Reason for Withdrawal

� Separation from Service (Termination/Retirement), effective ______________________

� Permanent/Total Disability, effective ______________________

� In-Service: GROSS Amount Requested $_________________ OR __________% of account

Step 3: Method of Withdrawal

� Full Withdrawal � Partial Withdrawal of $__________________

� Pay the distribution directly to me. Federal taxes of 20% will be withheld � Pay the distribution as a Rollover. � Traditional IRA � Roth IRA � Employer Plan Payee Name (to appear on check): ___________________________________________________________________________ Account Number (if applicable): ___________________________________ Payee’s Address: ________________________________________________________________________________________ _________________________________________________________________________________________

� Pay $_____________ (indicate $, % or BAL) of the distribution directly to me, withholding 20% federal income tax, and

$_____________ (indicate $, % or BAL) of the distribution as a Rollover. � Traditional IRA � Roth IRA � Employer Plan Payee Name (to appear on check): __________________________________________________________________________ Account Number (if applicable): ___________________________________ Payee’s Address: ________________________________________________________________________________________ ________________________________________________________________________________________

� Installments I wish to receive ______ payments per ______________ (monthly/quarterly/semi-annually/annually). I wish to receive $______________ (enter gross amount needed) per ______________ (monthly/quarterly/semi- annually/annually).

� Please provide an illustration of the monthly annuity options available. If married, my spouse’s date of birth is __________________ (mm/dd/yyyy)

� Defer my distribution until further notice or until ______/______/______ (available only if account balance is greater than $1,000)

� 1. Mail check to: � Participant � Rollover Institution � overnight ($20 fee applies)

� 2. Electronic Transfer: � ACH � Wire (obtain ACH & Wire information from your bank) Bank Name:_________________________________________________City/State/Zip of Bank:______________________________ ABA # (must be 9 digits): ________________________________ Account Number: _______________________________

Name on Account: ____________________________________________________ � Checking Account � Savings Account To be completed by former participants having an outstanding loan balance:

� I elect not to make additional loan payments. I understand this outstanding loan balance will be deemed a taxable distribution to me.

� I elect to pay off my outstanding loan(s) in full prior to my distribution request being processes. I will be receive payoff instructions shortly.

Step 4: Your Signature (Required Next Page) I certify that I have received the Special Tax Notice Regarding Plan Payments, which explains the tax consequences of, and the direct rollover option available with respect to my withdrawal from this retirement plan. I understand that I have the right to consider the information provided in the Special Tax Notice Regarding Plan Payments for at least 30 days. To the extent that my withdrawal from

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Clark-Pleasant Community School Corporation 401(a) and 403(b) Retirement PlanParticipant Name: __________________________________

the Plan can be made, or begin to be made, before the close of the 30-day period beginning with the date I received the Special Tax Notice Regarding Plan Payments, I hereby waive my right to consider the content of that notice for the full 30-day period and I hereby consent to the making of my withdrawal from the Plan as soon as administratively feasible. If your account balance is less than $1,000, absent an affirmative election on the distribution of your account, the Plan Administrator will automatically distribute the amount in your account in a cash distribution subject to income taxation. Further, if the balance of your account ever falls below the amount above, the account may be distributed without any further consent pursuant to the same provisions. I further certify and acknowledge I have the right to defer distribution of my account, if my account is greater than $1,000, until such time as I provide an affirmative election otherwise. If part of the Plan, I understand that I have the ability to continue to make investment decisions on my account, and I understand the investment options that are or may be available under the Plan (including fees) and that these options are subject to change under the Plan. I acknowledge I am responsible to refer to the Summary Plan Description for additional rules that might affect my decision to defer payment of my account, including but not limited to Forfeitures, Vesting, and Distributions. Finally, I acknowledge that if the balance of my account falls below the amount above, the account may be distributed without my further consent. I further certify that all information provided by me on this form is true and accurate. I certify under penalties of perjury that the Social Security number I specified is my correct taxpayer identification number. If I am a non-resident alien, I have attached IRS Form W8BEN and included my US taxpayer identification number with this form in order to claim any applicable tax treatment benefits. I understand that I will receive a Form 1099-R next January to file with my personal tax return. It is my responsibility to notify Niles Lankford Group, Inc. if my address changes prior to receiving this form. Participant’s Signature

Χ Date

Step 5: Spousal Consent

If you are married and have a vested account balance in excess of $5,000, spousal consent is required for all withdrawals except for Required Minimum Distributions. If you are single due to a divorce and the effective date of the divorce is within the past year, please attach a copy of the Divorce Decree.

To be completed by the Participant’s Spouse: I hereby consent to the election of withdrawal as indicated by my spouse. Further, I hereby acknowledge that I understand that this consent may deprive me of amounts which would otherwise be payable to me as surviving spouse upon the death of my spouse.

Spouse’s Printed Name

Spouse’s Signature

X Date

Notary Public (Notary Public seal/stamp required) or Plan Representative X

Date

Sworn before me this day: ____________________ State of: ___________________ County of: _______________________ Commission Expires: ______________________

** A processing fee of $50.00 will be deducted from your account when this request is processed. **

Mail completed form to: Niles Lankford Group, Inc. P.O. Box 329 / 1500 N. Oak Drive Plymouth, IN 46563-0329 Fax: (574) 936-5599 Email: distributions@nlgpension.com

Qualified Joint and Survivor Annuity Notice (applicable if your vested account balance is greater than $5,000)

What is a Qualified Joint and Survivor Annuity (QJSA)? Your plan states the automatic form of retirement benefit is a Qualified Joint and Survivor Annuity, unless you choose a different form of payment. If you are married, this Joint and Survivor Annuity form of payment provides you with monthly payments for your life. Upon your death, your spouse will receive a monthly payment equal to 50% of the monthly payment you receive prior to your death. Your spouse will receive this survivor benefit for the rest of his or her life. If you are not married, the QJSA will be paid to you in the form of a single life annuity unless you choose a different form of payment. A single life annuity gives you a monthly retirement payment for the rest of your life. Upon your death, no future benefits will be paid. What other forms of payment can I choose? The most common forms of non-QJSA payment include: lump sum, installments and annuities. Refer to your Summary Plan Description for the benefit options available to your plan. If you are married, your spouse must consent to the non-QJSA form of payment you elect. Your spouse’s consent must be in writing and witnessed by a notary public or a Plan Administrator/Plan Representative. The following chart illustrates the financial effect of the various payment options available:

Benefit Option

Description (You are the participant)

Estimated Monthly Payment *

Participant at age 65

Spouse at age 65

Joint and 50%

Survivor

You receive monthly payments for life. After your death, your spouse receives 50% of your monthly payment for the rest of his or her life.

$52 $26

Joint and 100%

Survivor

You receive monthly payments for life. After your death, your spouse receives 100% of your monthly payment for the rest of his or her life.

$48 $48

Single Life

Annuity

You receive monthly payments for life. Payments stop when you die. Your spouse or other beneficiary will receive no further payments

$58 $0

Life Annuity with 5 Year

Certain Period

You receive monthly payments for life. If you die before 5 years, your spouse or other beneficiary receives the remaining 60 guaranteed monthly payments. If you die after 5 years, your spouse or other beneficiary will receive no future payments.

$57 $0

Life Annuity With 10 Year Certain Period

You receive monthly payments for life. If you die before 10 years, your spouse or other beneficiary receives the remaining 120 guaranteed monthly payments. If you die after 10 years, your spouse or other beneficiary will receive no future payments.

$56 $0

Cash

You and your spouse, if any, agree to take a lump sum cash distribution now and receive no future payments.

$0 $0

*Figures above are based on a $10,000 withdrawal. The amounts shown are for illustration only. The actual amount of monthly benefit will depend on the annuity purchase rates in effect at the time of purchase and may result in higher or lower amounts.