VIRTUSA CORPORATION 401(K) PLAN

#10486 (12/2007) 710799

QP/401(k) Separation From Service SINSRCRIAPLT
Distribution Request Form
This form may be used if you have separated from service due to termination, disability
or attainment of normal retirement age and you wish to withdraw funds from the plan.

PARTICIPANT Social Security Number ________________________________________________________________________________________________

INFORMATION First Name___________________________________________ Last Name _____________________________________________________
Address______________________________________________________________________________________________________________
City_______________________________________________________ State____________________ Zip_____________________________
Check this box if your address has changed since you received your last participant statement with respect to the plan.

DISTRIBUTION NOTE: Refer to your summary plan description to determine whether installment and/or annuity payments are available to you in addition to
INSTRUCTIONS those types of distributions listed below. If installment and/or annuity payments are available to you and you wish to receive your distribution in
one of those forms, please see your plan administrator for additional details.
I wish to: (select one)
1. Receive a distribution of my entire vested account.
2. Receive $______________________ of my vested account balance.
3. Roll over my entire vested account balance to the plan and/or IRA described in the Direct Rollover Information section below.
4. Roll over $______________________ of my vested account balance to the plan and/or IRA described in the Direct Rollover
Information section below.
(If you choose item 4, select one of the following options)
Leave the remainder of my vested account balance in the plan.
Pay the remainder of my vested account balance to me.

DIRECT I wish to directly roll over my distribution(s) to the following plan and/or IRA. (Select from the listed retirement plans and IRAs and
ROLLOVER complete the financial organization information below. If you are rolling over to more than one type of plan or IRA, specify the percentage of the
INFORMATION amount to be rolled over into each account.)

Financial Organization/Trustee Financial Organization/Trustee Financial Organization/Trustee

Name and Address Name and Address Name and Address

QP/401(k) Plan 403(a) Plan Traditional IRA Traditional IRA

403(b) Plan 457(b) Plan Roth IRA Roth IRA
Account Number ____________________ Account Number ____________________ Account Number ____________________
Rollover Amount __________________% Rollover Amount __________________% Rollover Amount __________________%

NOTE: Eligible rollover distributions taken after December 31, 2007, may be rolled over to a Roth IRA. A rollover to a Roth IRA will result in
all pre-tax assets you roll over being included in your taxable income. Eligibility restrictions also apply to Roth IRA rollovers through 2009.
Consult with your tax advisor to determine if you are eligible to perform a Roth IRA rollover.

WITHHOLDING NOTE: This Withholding Election section only applies (for Federal withholding purposes) to a distribution that is not an eligible rollover distribution.
ELECTION Therefore, unless State withholding applies to your distribution, you may skip this Withholding Election section and proceed to the Authorization
Form W-4P section below if your distribution is eligible to be rolled over. Refer to the instructions to this form for assistance in making this determination.
OMB #1545-0074 If the boxes below are checked, Federal and State (if applicable) income tax will not be withheld from your distribution. If the boxes below are
not checked, Federal and State (if applicable) income tax will be withheld as described in the instructions unless you provide a specific number
of allowances and/or additional dollar amount or withholding rate percentage. Refer to the instructions provided with this form for more
information regarding withholding.
Do not withhold Federal Income Tax Do not withhold State Income Tax
Withholding Rate ____________% (must be at least 10 percent)

AUTHORIZATION I certify that I have read, understand and agree with the information provided in the instructions to this form. I acknowledge that
I have timely received a written explanation of the optional forms of benefit payments and have received, if applicable, my
spouse’s consent to take a distribution. I understand that I have 30 days to decide on my payment options and I elect to waive the
30-day period. I understand there may be a distribution fee charged against my account for this transaction and have been
advised to contact the plan administrator for a description of any applicable fees. I instruct the plan administrator to authorize this
distribution from the plan as soon as administratively possible.

Signature of Participant_________________________________________________________________ Date__________________________

Plan Administrator Use Only

Date of Separation From Service:_______________________
Reason for Separation From Service: Termination Attainment of Normal Retirement Age Disability
Signature of Plan Administrator _______________________________________________________ Date________________________
NOTE: To process this request in the most efficient manner, please utilize the website at https://www.sponsorinsight.com
This form may not be used to request a distribution in the form of installment or annuity payments. If a participant requests a distribution
in either of those forms of payment, please contact your Client Service Representative for further instructions.

Page 1 of 2 Copyright ©2009 Ascensus, Inc. All rights reserved.

#10486 (12/2007)
Using the QP/401(k) Separation From Service Distribution Request Form
Your plan permits you to withdraw your vested account balance when you separate from service with your employer due to termination, disability or
attainment of normal retirement age (if you are unsure of the plan’s normal retirement age, please refer to your summary plan description). If you have
separated from service for one of those reasons and you would like a distribution of all or a portion of your vested account balance, please read the
instructions below and complete the Separation From Service Distribution Request Form that accompanies these instructions. Once completed, the form
should be forwarded to your plan administrator for approval.
Participant Information
Please enter your social security number, full name, and address. In addition, please check the box if the address you have provided has changed since you
received your last statement.
Distribution Instructions
Please specify the amount you wish to receive and how you wish to receive it by choosing item one, two, three or four. If you elect a partial distribution (i.e., item
two or item four) you must indicate the dollar amount you wish to withdraw.
Your distribution will be deducted from your investment accounts proportionately and will be paid to you by check.
Direct Rollover Information
Eligible rollover distributions can be made directly to another QP/401(k), eligible 457(b), 403(a) or 403(b) plan, that will accept it (direct rollover) or, if you choose,
a Traditional or Roth IRA. If you choose to have your plan benefit paid to you, you will receive only 80% of the payment because the plan administrator is
required to withhold 20% of the payment and send it to the IRS as income tax withholding to be credited against your taxes. You cannot waive that withholding.
Eligible rollover distributions are all distributions from the plan except the following:
• Required minimum distributions;
• Certain installment payments that are a part of a series of equal (or almost equal) periodic payments that will last for your lifetime (or the joint lives of you
and your beneficiary) or for a specified period of 10 years or more; and
• Distributions due to hardship
Eligible rollover distributions taken after December 31, 2007, may be rolled over to a Roth IRA. If you choose to roll over to a Roth IRA, you must include all
pre-tax assets in your taxable income in the year of the distribution. In order to be eligible to perform a rollover to a Roth IRA you may not be married and
filing a separate federal income tax return, and you may not have modified adjusted gross income of $100,000 or more. In 2010, these eligibility requirements
are eliminated.
Please refer to the Distribution Notice for a description of options in detail.
Note: Your distribution cannot be rolled over to a SIMPLE IRA or Educational Savings Account.

Withholding Election
Distributions from your plan are subject to Federal (and in some cases, State) income tax withholding. For some distributions, you can elect not to have
withholding apply. However, you cannot waive withholding on any eligible rollover distribution that is paid to you. Refer to the information provided above
for the definition of eligible rollover distribution and a description of the mandatory 20% withholding. Therefore, unless State withholding applies to your
distribution, you may skip the Withholding Election section and proceed to the Authorization section of this form.
If your distribution is not an eligible rollover distribution, you may elect not to have withholding apply. Check the Do Not Withhold box if you do not want
any Federal (or State, if applicable) income tax withheld from your distribution. Even if you do not have income tax withheld, you are liable for payments of
income tax on the taxable portion of your distribution. You may also be subject to tax penalties under the estimated tax payment rules if your payments of
estimated tax and withholding, if any, are not adequate.
The election to not have withholding apply does not apply to any periodic or nonperiodic distributions that are delivered outside the U.S. or its possessions to
a U.S. citizen or resident alien. If you are a non-resident alien, do not complete this section. Your distributions are generally subject to a tax-withholding rate
of 30 percent. A reduced withholding rate, including exemption, may apply if there is a tax treaty between your country of residence and the United States,
and you submit Form W-8-BEN, Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding, or satisfy the documentation requirements as
provided under the regulations.
Periodic Distribution
For purposes of the withholding rules on distributions that are not eligible rollover distributions, a periodic distribution is one that is includible in your income
for tax purposes and that you receive in installments at regular intervals (e.g., annually, quarterly, monthly, etc.) over a period of time (more than 1 year).
Periodic distributions are treated as wages for purposes of withholding. If you do not waive withholding on your periodic distributions, Federal income
tax will be withheld from each payment as if you were a married individual claiming three withholding allowances. However, you can change the amount
of the withholding by completing the blanks below.
Withholding Allowances _______________ Marital Status: Single Married Married, but withhold at higher “single” rate
Additional dollar amount to be withheld $_______________________
Nonperiodic Distributions
If you do not waive withholding on any nonperiodic distribution that is not an eligible rollover distribution, Federal income tax will be withheld at the
rate of 10%, unless you specify a higher rate by completing the blank on the front of this form.
Remember that there are penalties for not paying enough tax during the year, either through withholding or estimated tax payments. New retirees, especially,
should see Publication 505. It explains the estimated tax requirements and penalties in detail. You may be able to avoid quarterly estimated tax payments by
having enough tax withheld from your pension or annuity using Form W-4P.
Authorization
You must authorize this distribution by signing and dating the Separation From Service Distribution Request Form.

Plan Administrator Use Only

Please verify that all information provided by the participant is accurate and complete. Enter the date the participant separated from service and the reason
for the separation from service. You acknowledge that the participant’s vested account balance will be calculated based on the data you have provided.
Please sign and date the form to acknowledge that you, acting as a named and authorized representative of the plan, confirm that the information
provided is complete and accurate and the request is in accordance with this plan. If the participant is married, you acknowledge that you have reviewed
the Participant Distribution Consent of Spouse Form, if applicable, and have found it to be in good order. In addition, you acknowledge that the
participant has taken the required minimum distribution, if applicable, prior to your authorization of a direct rollover. Finally, you authorize this request to
be processed as instructed.

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#10482NR-BD (4/2010)

QP/401(k) DISTRIBUTION NOTICE

Important Information About Your Qualified Retirement Plan Distribution

INTRODUCTION
As a participant in your employer’s qualified retirement plan, you have accumulated a vested account balance. You may receive your vested account balance
only if you incur a triggering event. You may incur a triggering event if:
• you are no longer working for your employer,
• you attain the normal retirement age indicated in the Plan,
• you become disabled under the Plan’s definition,
• your employer terminates the Plan,
• your Plan permits in-service distributions (may be limited to certain contribution sources),
• your Plan permits distributions during phased retirement (only applicable to certain plans and limited to participants that have attained age 62), or
• you incur a hardship (only applicable to certain plans and may be limited to certain contribution sources).
However, you must refer to your Summary Plan Description to identify the specific triggering events which apply under your Plan.
NOTE: Generally, payments from your employer’s qualified retirement plan must be delayed for a minimum of 30 days after you receive this notice, to allow you time to
consider your distribution options. Although you are entitled to consider your distribution options for a period of 30 days, you may waive this 30 day notice requirement. If
you waive the 30 day notice requirement, your employer must wait seven days from the date you received this notice before commencing distributions.
The law dictates the optional forms that your payments may take. The law also specifies how the different types of payments will be taxed. This notice
summarizes your distribution options and illustrates the financial effect and the tax consequences of each distribution option.
PART ONE of this notice describes the Plan payment options available to you. PART TWO describes your beneficiary(ies) payment options. PART THREE
contains a special tax notice, required by the IRS, that explains the tax treatment of your Plan payment that is not from a designated Roth account and
describes the rollover options available to you. PART FOUR contains a special tax notice, required by the IRS, that explains the tax treatment of your Plan
payment from a designated Roth account and describes the rollover options available to you.
NOTE: The payment amounts indicated in this notice are only examples. You may obtain financial projections based upon your account balance by submitting a request, in
writing, to the Plan administrator (usually the employer).

PART ONE – PAYMENT OPTIONS FOR PLAN PARTICIPANTS

IMPORTANT NOTICE TO PARTICIPANT

Read the following message before reviewing your options.
Of the three options listed below, some may not be available to you and you must refer to your Summary Plan Description to identify the specific payment options that apply
under your Plan.
If your vested account balance does not exceed the Plan’s cashout level at the time of distribution, the Plan administrator generally may pay your distribution
to you in a single cash payment, regardless of whether you consent to the distribution. A distribution made without your consent is called a cashout
distribution. If your Plan allows for cashout distributions of amounts less than $5,000, a cashout distribution of an amount greater than $1,000 that is an eligible
rollover distribution must be directly rolled over by the Plan administrator to an individual retirement account chosen by the Plan administrator. You may
subsequently transfer the IRA to another IRA provider, once the IRA has been established. However, if your vested account balance exceeds the Plan’s cashout
level, you must generally consent to the form of payment, and, therefore may, if you wish, postpone commencement of distributions from your account balance.
Your Employer intends for your Plan account to provide income to you during retirement. If you take a distribution prior to retiring or spend your retirement
savings too quickly, you may not have sufficient income to live on in retirement. If you terminate employment and leave your money in the Plan, a share of
the Plan’s administrative expenses may be charged to your account each year. Refer to your Plan administrator for an explanation of any administrative
expenses that may be charged to the accounts of terminated participants.
If you choose to roll over your vested account balance to an IRA or other eligible retirement plan, the distributing Plan’s investment options may not be
available under the receiving retirement arrangement and the fees may differ from those charged to you if your balance remained in the Plan. Complete
information concerning available investment options and fees currently charged by the Plan is available from your Plan administrator. Consult your financial
advisor for a description of investments available to you outside of the Plan and any applicable fees associated with them.

DISTRIBUTION OPTIONS
OPTION I — LUMP SUM PAYMENT
You may request a lump sum payment.

A. LUMP SUM PAYMENT DEFINED

A lump sum payment is the payment of your entire vested account balance.

B. FINANCIAL EFFECT AND TAX CONSEQUENCES OF A LUMP SUM PAYMENT

Generally a lump sum payment is included in your income and taxed in the year of the distribution. Most lump sum payments are eligible rollover
distributions and would, therefore, be subject to the 20 percent withholding rules unless directly rolled over to another plan or IRA. See Parts Three and
Four of this notice for more information.

OPTION II — INSTALLMENT PAYMENTS

You may elect to receive your vested account balance in installment payments. Installment payments for a period of less than 10 years are generally eligible
rollover distributions and would, therefore, be subject to the 20 percent withholding rules unless directly rolled over to another plan or IRA. See Parts Three
and Four of this notice for more information.

A. INSTALLMENT PAYMENTS DEFINED

Installment payments are payments distributed to you in any amount you choose at intervals that you determine within limits set by the trustee or
custodian. For example, the payments could be paid to you annually, semiannually, quarterly, or monthly. The payment schedule you choose cannot be
longer than your single life expectancy or, if you have a beneficiary named, the joint life expectancy of you and your beneficiary.

B. FINANCIAL EFFECT AND TAX CONSEQUENCES OF INSTALLMENT PAYMENTS

Generally, each installment payment will be included in your income in the year in which you receive it. For example, a participant who elects to receive
$500 per month will include $6,000 ($500 x 12 months) in income each tax year.
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#10482NR-BD (4/2010)

OPTION III — ANNUITY CONTRACT

You may purchase an annuity contract with your vested account balance. This distribution option allows you to choose the type of annuity contract you wish
to purchase. However, you cannot elect payments in the form of a life annuity.

A. ANNUITY CONTRACT DEFINED

You may use your vested account balance to purchase a term certain annuity or any other form of annuity except a life annuity. A term certain annuity
would distribute dollars to you and your beneficiary for a specified number of years.

B. FINANCIAL EFFECT AND TAX CONSEQUENCES OF THE ANNUITY

If you elect to use your vested account balance to purchase a term certain annuity, payments will be made to you (and, if applicable, the beneficiary of
your annuity) for a specified number of years. For example, assume a participant age 65 retires with a $10,000 account balance. A 10 year period certain
annuity may provide him or her with a monthly payment equal to $106.07. Generally, each payment is included in income in the year it is received.
The annuity will be provided by purchasing an annuity contract from an insurance company with your account balance under the plan.
This example is an estimate and should not be viewed as an assurance that an insurer is able to provide the specific amount disclosed.

PART TWO — PAYMENT OPTIONS FOR BENEFICIARIES OF DECEASED PLAN PARTICIPANTS

IMPORTANT NOTICE TO BENEFICIARY

If you are the designated beneficiary of a deceased participant’s vested account balance, you are eligible to receive a distribution. The form of the benefit depends on several
factors including, but not limited to, the type of plan and the amount in the participant’s account. Of the options listed above, some may not be available to you.

OPTION I — PARTICIPANT’S ACCOUNT BALANCE

If the participant’s vested account balance was $5,000 or less at the time of distribution, the Plan administrator is required to pay your distribution to you in a
single cash payment. If the participant’s vested account balance exceeded $5,000, you must consent to the form of payment.

OPTION II — TYPE OF PAYMENT

You may select Option I, II or III listed above. However, if you select the installment payment method described in Option II, the payment schedule you
choose cannot be longer than your single life expectancy. The rollover option described in Parts Three and Four is available only if you are the spouse of the
deceased participant. However, spouse and nonspouse beneficiaries may be able to directly roll over their balance to an inherited IRA as described in Parts
Three and Four of this notice.

PART THREE — PAYMENTS NOT FROM A DESIGNATED ROTH ACCOUNT

YOUR ROLLOVER OPTIONS

You are receiving this notice because all or a portion of a payment you are receiving from your retirement plan (the “Plan”) is eligible to be rolled over to an
IRA or an employer plan. This notice is intended to help you decide whether to do such a rollover.
This notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth account (a type of account with special tax
rules in some employer plans). If you also receive a payment from a designated Roth account in the Plan, refer to Part Four of this notice for information on
that payment, and the Plan administrator or the payor will tell you the amount that is being paid from each account.
Rules that apply to most payments from a plan are described in the “General Information About Rollovers” section. Special rules that only apply in certain
circumstances are described in the “Special Rules and Options” section.

GENERAL INFORMATION ABOUT ROLLOVERS

How can a rollover affect my taxes?
You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59½ and do not do a rollover, you will also have to pay a 10%
additional income tax on early distributions (unless an exception applies). However, if you do a rollover, you will not have to pay tax until you receive
payments later and the 10% additional income tax will not apply if those payments are made after you are age 59½ (or if an exception applies).

Where may I roll over the payment?

You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity) or an employer plan (a tax-qualified plan,
section 403(b) plan, or governmental section 457(b) plan) that will accept the rollover. The rules of the IRA or employer plan that holds the rollover will
determine your investment options, fees, and rights to payment from the IRA or employer plan (for example, no spousal consent rules apply to IRAs and
IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the IRA or employer plan.

How do I do a rollover?
There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover.
If you do a direct rollover, the Plan will make the payment directly to your IRA or an employer plan. You should contact the IRA sponsor or the administrator of
the employer plan for information on how to do a direct rollover.
If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible employer plan that will accept it. You will have 60 days
after you receive the payment to make the deposit. If you do not do a direct rollover, the Plan is required to withhold 20% of the payment for federal income
taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll over the entire payment in a 60-day
rollover, you must use other funds to make up for the 20% withheld. If you do not roll over the entire amount of the payment, the portion not rolled over will
be taxed and will be subject to the 10% additional income tax on early distributions if you are under age 59½ (unless an exception applies).

How much may I roll over?

If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except:
• Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)
• Required minimum distributions after age 70½ (or after death)
• Hardship distributions
• ESOP dividends
• Corrective distributions of contributions that exceed tax law limitations
• Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends)
• Cost of life insurance paid by the Plan

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#10482NR-BD (4/2010)

• Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment
• Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP (also, there will generally be adverse tax
consequences if you roll over a distribution of S corporation stock to an IRA).
The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.

If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions?
If you are under age 59½, you will have to pay the 10% additional income tax on early distributions for any payment from the Plan (including amounts
withheld for income tax) that you do not roll over, unless one of the exceptions listed below applies. This tax is in addition to the regular income tax on the
payment not rolled over.
The 10% additional income tax does not apply to the following payments from the Plan:
• Payments made after you separate from service if you will be at least age 55 in the year of the separation
• Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life expectancy (or the
lives or joint life expectancy of you and your beneficiary)
• Payments from a governmental defined benefit pension plan made after you separate from service if you are a public safety employee and you are at
least age 50 in the year of the separation
• Payments made due to disability
• Payments after your death
• Payments of ESOP dividends
• Corrective distributions of contributions that exceed tax law limitations
• Cost of life insurance paid by the Plan
• Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment
• Payments made directly to the government to satisfy a federal tax levy
• Payments made under a qualified domestic relations order (QDRO)
• Payments up to the amount of your deductible medical expenses
• Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more
than 179 days
• Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution.

If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from the IRA?
If you receive a payment from an IRA when you are under age 59½, you will have to pay the 10% additional income tax on early distributions from the IRA,
unless an exception applies. In general, the exceptions to the 10% additional income tax for early distributions from an IRA are the same as the exceptions
listed above for early distributions from a plan. However, there are a few differences for payments from an IRA, including:
• There is no exception for payments after separation from service that are made after age 55.
• The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a divorce or
separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse).
• The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to whether you
have had a separation from service.
• There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified first-time
home purchase, and (3) payments after you have received unemployment compensation for 12 consecutive weeks (or would have been eligible to
receive unemployment compensation but for self-employed status).

Will I owe State income taxes?

This notice does not describe any State or local income tax rules (including withholding rules).

SPECIAL RULES AND OPTIONS

If your payment includes after-tax contributions
After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable portion of your after-tax contributions is
generally included in the payment. If you have pre-1987 after-tax contributions maintained in a separate account, a special rule may apply to determine
whether the after-tax contributions are included in a payment.
You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a 60-day rollover. You must keep track of the
aggregate amount of the after-tax contributions in all of your IRAs (in order to determine your taxable income for later payments from the IRAs). If you do a
direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, each of the payments will include an allocable portion of the
after-tax contributions. If you do a 60-day rollover to an IRA of only a portion of the payment made to you, the after-tax contributions are treated as rolled
over last. For example, assume you are receiving a complete distribution of your benefit which totals $12,000, of which $2,000 is after-tax contributions. In this
case, if you roll over $10,000 to an IRA in a 60-day rollover, no amount is taxable because the $2,000 amount not rolled over is treated as being after-tax
contributions.
You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a direct rollover (and only if the receiving plan
separately accounts for after-tax contributions and is not a governmental section 457(b) plan). You can do a 60-day rollover to an employer plan of part of a
payment that includes after-tax contributions, but only up to the amount of the payment that would be taxable if not rolled over.

If you miss the 60-day rollover deadline

Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to waive the deadline under certain extraordinary
circumstances, such as when external events prevented you from completing the rollover by the 60-day rollover deadline. To apply for a waiver, you must file
a private letter ruling request with the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more information, see IRS
Publication 590, Individual Retirement Arrangements (IRAs).

If your payment includes employer stock that you do not roll over
If you do not do a rollover, you can apply a special rule to payments of employer stock (or other employer securities) that are either attributable to after-tax
contributions or paid in a lump sum after separation from service (or after age 59½, disability, or the participant’s death). Under the special rule, the net
unrealized appreciation on the stock will not be taxed when distributed from the Plan and will be taxed at capital gain rates when you sell the stock. Net
unrealized appreciation is generally the increase in the value of employer stock after it was acquired by the Plan. If you do a rollover for a payment that
includes employer stock (for example, by selling the stock and rolling over the proceeds within 60 days of the payment), the special rule relating to the
distributed employer stock will not apply to any subsequent payments from the IRA or employer plan. The Plan administrator can tell you the amount of any
net unrealized appreciation.

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If you have an outstanding loan that is being offset

If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan, typically when your employment ends. The loan
offset amount is treated as a distribution to you at the time of the offset and will be taxed (including the 10% additional income tax on early distributions,
unless an exception applies) unless you do a 60-day rollover in the amount of the loan offset to an IRA or employer plan.

If you were born on or before January 1, 1936

If you were born on or before January 1, 1936 and receive a lump sum distribution that you do not roll over, special rules for calculating the amount of the tax
on the payment might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income.

If your payment is from a governmental section 457(b) plan

If the Plan is a governmental section 457(b) plan, the same rules described elsewhere in this notice generally apply, allowing you to roll over the payment to
an IRA or an employer plan that accepts rollovers. One difference is that, if you do not do a rollover, you will not have to pay the 10% additional income tax
on early distributions from the Plan even if you are under age 59½ (unless the payment is from a separate account holding rollover contributions that were
made to the Plan from a tax-qualified plan, a section 403(b) plan, or an IRA). However, if you do a rollover to an IRA or to an employer plan that is not a
governmental section 457(b) plan, a later distribution made before age 59½ will be subject to the 10% additional income tax on early distributions (unless an
exception applies). Other differences are that you cannot do a rollover if the payment is due to an “unforeseeable emergency” and the special rules under “If
your payment includes employer stock that you do not roll over” and “If you were born on or before January 1, 1936” do not apply.

If you are an eligible retired public safety officer and your pension payment is used to pay for health coverage or qualified long-term care insurance
If the Plan is a governmental plan, you retired as a public safety officer, and your retirement was by reason of disability or was after normal retirement age,
you can exclude from your taxable income plan payments paid directly as premiums to an accident or health plan (or a qualified long-term care insurance
contract) that your employer maintains for you, your spouse, or your dependents, up to a maximum of $3,000 annually. For this purpose, a public safety
officer is a law enforcement officer, firefighter, chaplain, or member of a rescue squad or ambulance crew.

If you roll over your payment to a Roth IRA

You can roll over a payment from the Plan made before January 1, 2010 to a Roth IRA only if your modified adjusted gross income is not more than $100,000
for the year the payment is made to you and, if married, you file a joint return. These limitations do not apply to payments made to you from the Plan after
2009. If you wish to roll over the payment to a Roth IRA, but you are not eligible to do a rollover to a Roth IRA until after 2009, you can do a rollover to a
traditional IRA and then, after 2009, elect to convert the traditional IRA into a Roth IRA.
If you roll over the payment to a Roth IRA, a special rule applies under which the amount of the payment rolled over (reduced by any after-tax amounts) will
be taxed. However, the 10% additional income tax on early distributions will not apply (unless you take the amount rolled over out of the Roth IRA within 5
years, counting from January 1 of the year of the rollover). For payments from the Plan during 2010 that are rolled over to a Roth IRA, the taxable amount can
be spread over a 2-year period starting in 2011.
If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified distributions will not be taxed (including earnings after the
rollover). A qualified distribution from a Roth IRA is a payment made after you are age 59½ (or after your death or disability, or as a qualified first-time
homebuyer distribution of up to $10,000) and after you have had a Roth IRA for at least 5 years. In applying this 5-year rule, you count from January 1 of the
year for which your first contribution was made to a Roth IRA. Payments from the Roth IRA that are not qualified distributions will be taxed to the extent of
earnings after the rollover, including the 10% additional income tax on early distributions (unless an exception applies). You do not have to take required
minimum distributions from a Roth IRA during your lifetime. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).
You cannot roll over a payment from the Plan to a designated Roth account in an employer plan.

If you are not a plan participant

Payments after death of the participant. If you receive a distribution after the participant’s death that you do not roll over, the distribution will generally be
taxed in the same manner described elsewhere in this notice. However, the 10% additional income tax on early distributions and the special rules for public
safety officers do not apply, and the special rule described under the section “If you were born on or before January 1, 1936” applies only if the participant
was born on or before January 1, 1936.
If you are a surviving spouse. If you receive a payment from the Plan as the surviving spouse of a deceased participant, you have the same rollover
options that the participant would have had, as described elsewhere in this notice. In addition, if you choose to do a rollover to an IRA, you may treat the
IRA as your own or as an inherited IRA.
An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before you are age 59½ will be subject to the 10%
additional income tax on early distributions (unless an exception applies) and required minimum distributions from your IRA do not have to start until
after you are age 70½.
If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10% additional income tax on early distributions. However, if
the participant had started taking required minimum distributions, you will have to receive required minimum distributions from the inherited IRA. If
the participant had not started taking required minimum distributions from the Plan, you will not have to start receiving required minimum distributions
from the inherited IRA until the year the participant would have been age 70½.
If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan because of the participant’s death and you are a designated
beneficiary other than a surviving spouse, the only rollover option you have is to do a direct rollover to an inherited IRA. Payments from the inherited IRA
will not be subject to the 10% additional income tax on early distributions. You will have to receive required minimum distributions from the inherited IRA.
If you do not do a direct rollover to an inherited IRA, the Plan is required to withhold 20% of the payment for federal income taxes. You cannot waive the
20% withholding.
Payments under a qualified domestic relations order. If you are the spouse or former spouse of the participant who receives a payment from the Plan under a
qualified domestic relations order (QDRO), you generally have the same options the participant would have (for example, you may roll over the payment to your
own IRA or an eligible employer plan that will accept it). Payments under the QDRO will not be subject to the 10% additional income tax on early distributions.

If you are a nonresident alien

If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer plan, instead of withholding 20%, the Plan is generally
required to withhold 30% of the payment for federal income taxes. If the amount withheld exceeds the amount of tax you owe (as may happen if you do a
60-day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form 1042-S. See Form W-8BEN for claiming that you are
entitled to a reduced rate of withholding under an income tax treaty. For more information, see also IRS Publication 519, U.S. Tax Guide for Aliens, and IRS
Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities.

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Other special rules

If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct rollover will apply to all later payments in the series
(unless you make a different choice for later payments).
If your payments for the year are less than $200 (not including payments from a designated Roth account in the Plan), the Plan is not required to allow you to
do a direct rollover and is not required to withhold for federal income taxes. However, you may do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout of more than $1,000 (not including payments from a designated Roth account in the Plan) will be directly
rolled over to an IRA chosen by the Plan administrator or the payor. A mandatory cashout is a payment from a plan to a participant made before age 62 (or
normal retirement age, if later) and without consent, where the participant’s benefit does not exceed $5,000 (not including any amounts held under the plan as
a result of a prior rollover made to the plan).
You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see IRS Publication 3, Armed Forces’ Tax Guide.

FOR MORE INFORMATION

You may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking a payment from the Plan. Also, you can find more
detailed information on the federal tax treatment of payments from employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 590,
Individual Retirement Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These publications are available from a local IRS
office, on the web at www.irs.gov, or by calling 1-800-TAX-FORM.

PART FOUR — PAYMENTS FROM A DESIGNATED ROTH ACCOUNT

YOUR ROLLOVER OPTIONS

You are receiving this notice because all or a portion of a payment you are receiving from your retirement plan (the “Plan”) is eligible to be rolled over to a
Roth IRA or designated Roth account in an employer plan. This notice is intended to help you decide whether to do a rollover.
This notice describes the rollover rules that apply to payments from the Plan that are from a designated Roth account. If you also receive a payment from the
Plan that is not from a designated Roth account, refer to Part Three of this notice for information on that payment, and the Plan administrator or the payor
will tell you the amount that is being paid from each account.
Rules that apply to most payments from a designated Roth account are described in the “General Information About Rollovers” section. Special rules that
only apply in certain circumstances are described in the “Special Rules and Options” section.

GENERAL INFORMATION ABOUT ROLLOVERS

How can a rollover affect my taxes?
After-tax contributions included in a payment from a designated Roth account are not taxed, but earnings might be taxed. The tax treatment of earnings
included in the payment depends on whether the payment is a qualified distribution. If a payment is only part of your designated Roth account, the payment
will include an allocable portion of the earnings in your designated Roth account.
If the payment from the Plan is not a qualified distribution and you do not do a rollover to a Roth IRA or a designated Roth account in an employer plan, you
will be taxed on the earnings in the payment. If you are under age 59½, a 10% additional income tax on early distributions will also apply to the earnings
(unless an exception applies). However, if you do a rollover, you will not have to pay taxes currently on the earnings and you will not have to pay taxes later
on payments that are qualified distributions.
If the payment from the Plan is a qualified distribution, you will not be taxed on any part of the payment even if you do not do a rollover. If you do a rollover,
you will not be taxed on the amount you roll over and any earnings on the amount you roll over will not be taxed if paid later in a qualified distribution.
A qualified distribution from a designated Roth account in the Plan is a payment made after you are age 59½ (or after your death or disability) and after you
have had a designated Roth account in the Plan for at least 5 years. In applying the 5-year rule, you count from January 1 of the year your first contribution
was made to the designated Roth account. However, if you did a direct rollover to a designated Roth account in the Plan from a designated Roth account in
another employer plan, your participation will count from January 1 of the year your first contribution was made to the designated Roth account in the Plan
or, if earlier, to the designated Roth account in the other employer plan.

Where may I roll over the payment?

You may roll over the payment to either a Roth IRA (a Roth individual retirement account or Roth individual retirement annuity) or a designated Roth account
in an employer plan (a tax-qualified plan or section 403(b) plan) that will accept the rollover. The rules of the Roth IRA or employer plan that holds the rollover
will determine your investment options, fees, and rights to payment from the Roth IRA or employer plan (for example, no spousal consent rules apply to Roth
IRAs and Roth IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the Roth IRA or the designated
Roth account in the employer plan. In general, these tax rules are similar to those described elsewhere in this notice, but differences include:
• If you do a rollover to a Roth IRA, all of your Roth IRAs will be considered for purposes of determining whether you have satisfied the 5-year rule
(counting from January 1 of the year for which your first contribution was made to any of your Roth IRAs).
• If you do a rollover to a Roth IRA, you will not be required to take a distribution from the Roth IRA during your lifetime and you must keep track of
the aggregate amount of the after-tax contributions in all of your Roth IRAs (in order to determine your taxable income for later Roth IRA payments
that are not qualified distributions).
• Eligible rollover distributions from a Roth IRA can only be rolled over to another Roth IRA.

How do I do a rollover?
There are two ways to do a rollover. You can either do a direct rollover or a 60-day rollover.
If you do a direct rollover, the Plan will make the payment directly to your Roth IRA or designated Roth account in an employer plan. You should contact the
Roth IRA sponsor or the administrator of the employer plan for information on how to do a direct rollover.
If you do not do a direct rollover, you may still do a rollover by making a deposit within 60 days into a Roth IRA, whether the payment is a qualified or
nonqualified distribution. In addition, you can do a rollover by making a deposit within 60 days into a designated Roth account in an employer plan if the
payment is a nonqualified distribution and the rollover does not exceed the amount of the earnings in the payment. You cannot do a 60-day rollover to an
employer plan of any part of a qualified distribution. If you receive a distribution that is a nonqualified distribution and you do not roll over an amount at
least equal to the earnings allocable to the distribution, you will be taxed on the amount of those earnings not rolled over, including the 10% additional
income tax on early distributions if you are under age 59½ (unless an exception applies).
If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, each of the payments will include an allocable
portion of the earnings in your designated Roth account.

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If you do not do a direct rollover and the payment is not a qualified distribution, the Plan is required to withhold 20% of the earnings for federal income taxes
(up to the amount of cash and property received other than employer stock). This means that, in order to roll over the entire payment in a 60-day rollover to a
Roth IRA, you must use other funds to make up for the 20% withheld.

How much may I roll over?

If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except:
• Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and your
beneficiary)
• Required minimum distributions after age 70½ (or after death)
• Hardship distributions
• ESOP dividends
• Corrective distributions of contributions that exceed tax law limitations
• Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends)
• Cost of life insurance paid by the Plan
• Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment
• Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP (also, there will generally be adverse tax
consequences if S corporation stock is held by an IRA).
The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.

If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions?
If a payment is not a qualified distribution and you are under age 59½, you will have to pay the 10% additional income tax on early distributions with respect
to the earnings allocated to the payment that you do not roll over (including amounts withheld for income tax), unless one of the exceptions listed below
applies. This tax is in addition to the regular income tax on the earnings not rolled over.
The 10% additional income tax does not apply to the following payments from the Plan:
• Payments made after you separate from service if you will be at least age 55 in the year of the separation
• Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life expectancy (or the
lives or joint life expectancy of you and your beneficiary)
• Payments made due to disability
• Payments after your death
• Payments of ESOP dividends
• Corrective distributions of contributions that exceed tax law limitations
• Cost of life insurance paid by the Plan
• Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment
• Payments made directly to the government to satisfy a federal tax levy
• Payments made under a qualified domestic relations order (QDRO)
• Payments up to the amount of your deductible medical expenses
• Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more
than 179 days
• Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution.

If I do a rollover to a Roth IRA, will the 10% additional income tax apply to early distributions from the IRA?
If you receive a payment from a Roth IRA when you are under age 59½, you will have to pay the 10% additional income tax on early distributions on the
earnings paid from the Roth IRA, unless an exception applies or the payment is a qualified distribution. In general, the exceptions to the 10% additional
income tax for early distributions from a Roth IRA listed above are the same as the exceptions for early distributions from a plan. However, there are a few
differences for payments from a Roth IRA, including:
• There is no special exception for payments after separation from service.
• The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a divorce or
separation agreement, a tax-free transfer may be made directly to a Roth IRA of a spouse or former spouse).
• The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to whether you
have had a separation from service.
• There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified first-time
home purchase, and (3) payments after you have received unemployment compensation for 12 consecutive weeks (or would have been eligible to
receive unemployment compensation but for self-employed status).

Will I owe State income taxes?

This notice does not describe any State or local income tax rules (including withholding rules).

SPECIAL RULES AND OPTIONS

If you miss the 60-day rollover deadline
Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to waive the deadline under certain extraordinary
circumstances, such as when external events prevented you from completing the rollover by the 60-day rollover deadline. To apply for a waiver, you must file
a private letter ruling request with the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more information, see IRS
Publication 590, Individual Retirement Arrangements (IRAs).

If your payment includes employer stock that you do not roll over
If you receive a payment that is not a qualified distribution and you do not roll it over, you can apply a special rule to payments of employer stock (or other
employer securities) that are paid in a lump sum after separation from service (or after age 59½, disability, or the participant’s death). Under the special rule, the
net unrealized appreciation on the stock included in the earnings in the payment will not be taxed when distributed to you from the Plan and will be taxed at
capital gain rates when you sell the stock. If you do a rollover to a Roth IRA for a nonqualified distribution that includes employer stock (for example, by
selling the stock and rolling over the proceeds within 60 days of the distribution), you will not have any taxable income and the special rule relating to the
distributed employer stock will not apply to any subsequent payments from the Roth IRA or employer plan. Net unrealized appreciation is generally the
increase in the value of the employer stock after it was acquired by the Plan. The Plan administrator can tell you the amount of any net unrealized appreciation.
If you receive a payment that is a qualified distribution that includes employer stock and you do not roll it over, your basis in the stock (used to determine
gain or loss when you later sell the stock) will equal the fair market value of the stock at the time of the payment from the Plan.

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If you have an outstanding loan that is being offset

If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan, typically when your employment ends. The loan
offset amount is treated as a distribution to you at the time of the offset and, if the distribution is a nonqualified distribution, the earnings in the loan offset
will be taxed (including the 10% additional income tax on early distributions, unless an exception applies) unless you do a 60-day rollover in the amount of
the earnings in the loan offset to a Roth IRA or designated Roth account in an employer plan.

If you receive a nonqualified distribution and you were born on or before January 1, 1936
If you were born on or before January 1, 1936, and receive a lump sum distribution that is not a qualified distribution and that you do not roll over, special
rules for calculating the amount of the tax on the earnings in the payment might apply to you. For more information, see IRS Publication 575, Pension and
Annuity Income.

If you receive a nonqualified distribution, are an eligible retired public safety officer, and your pension payment is used to pay for health coverage or
qualified long-term care insurance
If the Plan is a governmental plan, you retired as a public safety officer, and your retirement was by reason of disability or was after normal retirement age,
you can exclude from your taxable income nonqualified distributions paid directly as premiums to an accident or health plan (or a qualified long-term care
insurance contract) that your employer maintains for you, your spouse, or your dependents, up to a maximum of $3,000 annually. For this purpose, a public
safety officer is a law enforcement officer, firefighter, chaplain, or member of a rescue squad or ambulance crew.

If you are not a plan participant

Payments after death of the participant. If you receive a distribution after the participant’s death that you do not roll over, the distribution will generally be
taxed in the same manner described elsewhere in this notice. However, whether the payment is a qualified distribution generally depends on when the
participant first made a contribution to the designated Roth account in the Plan. Also, the 10% additional income tax on early distributions and the special
rules for public safety officers do not apply, and the special rule described under the section “If you receive a nonqualified distribution and you were born on
or before January 1, 1936” applies only if the participant was born on or before January 1, 1936.
If you are a surviving spouse. If you receive a payment from the Plan as the surviving spouse of a deceased participant, you have the same rollover
options that the participant would have had, as described elsewhere in this notice. In addition, if you choose to do a rollover to a Roth IRA, you may treat
the Roth IRA as your own or as an inherited Roth IRA.
A Roth IRA you treat as your own is treated like any other Roth IRA of yours, so that you will not have to receive any required minimum distributions
during your lifetime and earnings paid to you in a nonqualified distribution before you are age 59½ will be subject to the 10% additional income tax on
early distributions (unless an exception applies).
If you treat the Roth IRA as an inherited Roth IRA, payments from the Roth IRA will not be subject to the 10% additional income tax on early
distributions. An inherited Roth IRA is subject to required minimum distributions. If the participant had started taking required minimum distributions
from the Plan, you will have to receive required minimum distributions from the inherited Roth IRA. If the participant had not started taking required
minimum distributions, you will not have to start receiving required minimum distributions from the inherited Roth IRA until the year the participant
would have been age 70½.
If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan because of the participant’s death and you are a
designated beneficiary other than a surviving spouse, the only rollover option you have is to do a direct rollover to an inherited Roth IRA. Payments from
the inherited Roth IRA, even if made in a nonqualified distribution, will not be subject to the 10% additional income tax on early distributions. You will
have to receive required minimum distributions from the inherited Roth IRA.
If you do not do a direct rollover to an inherited IRA, the Plan is required to withhold 20% of the payment for federal income taxes. You cannot waive the
20% withholding.
Payments under a qualified domestic relations order. If you are the spouse or a former spouse of the participant who receives a payment from the Plan under
a qualified domestic relations order (QDRO), you generally have the same options the participant would have (for example, you may roll over the payment as
described in this notice).

If you are a nonresident alien

If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer plan, instead of withholding 20%, the Plan is generally
required to withhold 30% of the payment for federal income taxes. If the amount withheld exceeds the amount of tax you owe (as may happen if you do a
60-day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form 1042-S. See Form W-8BEN for claiming that you are
entitled to a reduced rate of withholding under an income tax treaty. For more information, see also IRS Publication 519, U.S. Tax Guide for Aliens, and IRS
Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities.

Other special rules

If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct rollover will apply to all later payments in the series
(unless you make a different choice for later payments).
If your payments for the year (only including payments from the designated Roth account in the Plan) are less than $200, the Plan is not required to allow you
to do a direct rollover and is not required to withhold for federal income taxes. However, you can do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout from the designated Roth account in the Plan of more than $1,000 will be directly rolled over to a Roth IRA
chosen by the Plan administrator or the payor. A mandatory cashout is a payment from a plan to a participant made before age 62 (or normal retirement age,
if later) and without consent, where the participant’s benefit does not exceed $5,000 (not including any amounts held under the plan as a result of a prior
rollover made to the plan).
You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see IRS Publication 3, Armed Forces’ Tax Guide.

FOR MORE INFORMATION

You may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking a payment from the Plan. Also, you can find more
detailed information on the federal tax treatment of payments from employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 590,
Individual Retirement Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These publications are available from a local IRS
office, on the web at www.irs.gov, or by calling 1-800-TAX-FORM.

Page 7 of 7 Copyright ©2010 Ascensus, Inc. All rights reserved.