Distribution Request Form

DISTRIBUTION REQUEST FORM

A 1099R WILL BE ISSUED BY JANUARY 31ST FOLLOWING THE CALENDAR YEAR OF DISTRIBUTION

SECTION 1 - PARTICIPANT INFORMATION

Participant Name SSN DOB

Beneficiary Name SSN DOB

Address City State Zip

Phone Number Email

Plan

SECTION 2 - PARTICIPANT IDENTIFICATION

Please attach a copy of your photo I.D.

SECTION 3 - ELECTION [a $30 Withdrawal fee will be assessed for all Rollovers and Cash Distributions]

After reading the Special Tax Notice that is available on keatinginc.com. Regarding Plan Payments, I, the undersigned Participant, make the following distribution election: Choose (A), (B), or (C)

SECTION 4 - INFORMATION FOR DIRECT ROLLOVER [Complete if you checked (A) or (B) in Section 3]

Please make sure to:

■ Attach a transfer form and/or letter of acceptance (with account numbers) for each rollover request.

■ Include separate account information for Pre-Tax (including any Employer Contributions) and Roth sources.

PRE-TAX Choose (A) or (B):

A. Please send a check to the following: (Only allowed for distribution amounts less than $50,000) (additional $10 fee)

Name of IRA or Plan:

Make check payable to: Account Number:

Address Rollover:

Please expedite my Rollover Check (additional $25 fee)

B. Electronic Funds Transfer: (Mandatory for distributions amounts over $50,000)

Direct Deposit (ACH)

Wire (Verify with receiving bank if they accept wires and/or charge a fee)(additional $15 fee)

Check one: Checking Account Savings Account

Bank Name: City/State:

Routing Number: Account Number (Bank):

Name on Account: Rollover Account Number:

ROTH (AFTER-TAX) Choose (A) or (B):

A. Please send a check to the following: (Only allowed for distribution amounts less than $50,000) (additional $10 fee)

Name of IRA or Plan:

Make check payable to: Account Number:

Address Rollover:

Please expedite my Rollover Check (additional $25 fee)

B. Electronic Funds Transfer: (Mandatory for distributions amounts over $50,000)

Direct Deposit (ACH)

Wire (Verify with receiving bank if they accept wires and/or charge a fee)(additional $15 fee)

Check one: Checking Account Savings Account

Bank Name: City/State:

Routing Number: Account Number (Bank):

Name on Account: Rollover Account Number:

SECTION 5 - INFORMATION FOR NON-ROLLOVER [Complete if you checked (B2, B3 or C) in Section 3]

Send a check to my home address. (Only available for distribution amounts less than $50,000)(additional $10 fee)

Please expedite my Rollover Check (additional $25 fee)

Electronic Funds Transfer: (Mandatory for distributions amounts over $50,000)

Direct Deposit (ACH) Wire (Verify with receiving bank if they accept wires and/or charge a fee)(additional $15 fee)

Check one: Checking Account Savings Account

Bank Name: City/State:

Routing Number: Account Number:

Name on Account:

SECTION 6 - INCOME TAX WITHHOLDING [Complete if you checked (B) or (C) in Section 3]

The minimum income tax automatically withheld from cash distributions is:

■ 20% Federal

■ 5% State (if your state requires income tax to be withheld)

ADDITIONAL WITHHOLDING ONLY (only indicate withholdings in addition to the indicated minimums):

Withhold an additional % for Federal Income Taxes.

Withhold an additional % for State Income Taxes.

SECTION 7 - WAIVER OF MINIMUM NOTICE PERIOD

I consent to an immediate distribution of my Vested Account Balance. I affirmatively waive any unexpired portion of the minimum 30-day notice period during which I may consent to a distribution from the Plan.

SECTION 8 - PARTICIPANT SIGNATURE

I acknowledge that I have either consulted my personal tax advisor or elected to proceed without consultation. I do hereby release the Trustees, the plan and employer of, from and against any and all claims the undersigned may have hereafter claim to have against said Trustees and said employer with respect to the undersigned’s interest in said Trust. Nothing contained in this release is intended to relieve any fiduciary of any obligation or duty under ERISA, or to violate the provisions of Section 410 of ERISA.