CCOERA 401(a) RETIREMENT PLAN LOANS Loan Eligibility Requirements

The Minimum loan is $2,500. You may borrow up to 50% of your 401(a)

VESTED Account Balance. The minimum 401(a) VESTED Account Balance must be at least $5,000. The Maximum loan is the lesser of $50,000 or 50% of your 401(a) VESTED Account Balance.

The combined loans on both the 401(a) and the 457 plans may not exceed the $50,000 Maximum loan amount. Participants may only borrow a total amount of $50,000 in one rolling 12 month period.

Loans must be paid via payroll deductions within 1 to 5 years, unless a principal residence loan option is elected. Loans may be paid off early.

Loans will reduce the participants account balance by the amount of the loan and charge interest that equals Prime + 1%.

All loans are 100% due and payable upon separation from service. If not paid off immediately, they are reported as taxable distributions to the IRS and subject to potential tax penalties. Participants with In-Service loan defaults will be permanently disqualified from using the loan program.

Loan Processing Requirements* 1. All participants interested in a loan must “first” call the following number to

determine their Eligibility and to obtain a Loan Quote:

(800) 352-0313, press 0

2. After obtaining a Loan Quote, you will need to complete the attached Loan Application. This application is specifically designed for your Employer. However, it must be faxed to GWRS at:

(866) 745-5766

* This is the only procedure available for processing your loan request. Your employer’s information has already been completed for your convenience. DO NOT forward your application to your employer’s Payroll or HR department. All applications must be faxed to the above GWRS fax number to be processed. Please direct all phone calls to CCOERA or GWRS. They will be reviewing & approving all Loan Applications.

1/12

][STD FLNACC ][12/19/11 ][Page 1 of 4 ][A06:120611

Account Reduction Loan Application401(a) Plan

Use black or blue ink when completing this form. For questions regarding this form, contact Service Provider at 1-800-352-0313.

98721-01 CCOERA 401(A) Plan

Participant InformationAccount extension identifies funds transferred to abeneficiary due to death, alternate payee due to divorceor a participant with multiple accounts.

❑ ❑

❑ ❑

(Notary or witness required in Section D)

Loan Options (Please read Loan Provisions before completing)

Loan Refinance (Complete this section only if refinancing existing loan(s))

❑❑

Type of Loan (Select ONE type) (Do not complete for refinance)

❑ General Purpose Loan (Available for any purpose)

❑ Principal Residence Loan (Available only to purchase or build a principal residence. Not available to renovate or refinance a principalresidence)

Required Documentation:

Amount of Loan

Refinancing Existing Loan(s):

Minimum Loan:

❑ (Optional)

Check Amount:

Maximum Loan:

Amount Requested:

Fee Information:

Method of Payment (To be verified by my Employer)

Payroll Deduction

(weekly, bi-weekly, semi-monthly or monthly)

Jefferson County 1640

Rebecca Norton

Semi-monthly

][STD FLNACC ][12/19/11 ][Page 2 of 4 ][A06:120611

Signatures and Consent

Participant Consent

It is entirely my responsibility to ensure that timely loan payments are being remitted to Service Provider to avoid the taxconsequences associated with a defaulted Plan loan.Change of Address/Alternate Address:

Participant Signature Date (Required)

Change of Address/Alternate Address Notarization (May also be witnessed by my authorized Plan Administrator/Trustee)

Active Employees Only -

The date I sign this form must match the date on which my signature was notarized or witnessed.

Statement of Notary NOTE: Notary seal must be visible.

(or affirmed)SEAL

(name of participant)

Plan Administrator/Trustee Witness Signature

Plan Administrator/Trustee Witness Signature Date (Required)

Mailing Instructions

Participant®

][STD FLNACC ][12/19/11 ][Page 3 of 4 ][A06:120611

Loan Provisions

Loans may be denied to individuals who have previously defaulted on a loan, subject to the terms of the Plan’s Loan Policy

Incomplete or Inaccurate Information

Refinance OptionLoan Refinance

Detailed Loan InformationAmount of Loan

Cost

Interest Rate Determination

Source and Application of Funds

Delivery MethodLoan Check

Express Delivery

Detailed Payment InformationRepayment

Prepayment

Principal Reduction Method

][STD FLNACC ][12/19/11 ][Page 4 of 4 ][A06:120611

Returned Payment Checks

Default

DistributionsFull Distributions

Partial Distributions

Death Distributions

Leave of Absence