Employee Stock Ownership Plan Packs

EMPLOYEE STOCK OWNERSHIP PLAN PACKS

This form documents the contents and participant elections for distribution with respect to an Employee Stock Ownership Plan (the Plan). Completion of this Pack acknowledges delivery of required documents to the participant, records participant elections where applicable, and collects administrative information necessary for Plan recordkeeping and compliance.

Plan and Employer Information

Plan Name:

Employer/Company Name:

Employer EIN:    Plan Number:

Plan Effective Date:

Pack Contents (to be completed by Plan Administrator)

The administrator certifies that the following documents are included in the Pack. Check all that apply.

  Plan Document

  Summary Plan Description (SPD)

  Enrollment / Participation Form

  Beneficiary Designation Form

  Allocation Statement

  Vesting Schedule

  Trustee Certification / Trust Agreement Excerpt

  Notice of Allocation / Participant Statement

Participant Information

Hire Date:    Date of Birth:

Participant Elections and Acknowledgments

Participation Election (select one):     I elect to participate in the Plan   I decline participation in the Plan

Consent to Electronic Delivery:   I consent to receive Plan notices and participant statements electronically as permitted by the Plan and applicable law.

Tax Withholding Acknowledgment:   I understand that distributions and certain transactions may give rise to tax withholding and I will consult my tax advisor regarding tax consequences.

Allocation / Issuance Schedule

Record of stock allocations or unitizations to this participant (administrative use). Enter grant date as MM/DD/YYYY.

Beneficiary Designation

Primary Beneficiary 1 — Name:   Relationship:

SSN:   Allocation %:

Contingent Beneficiary 1 — Name:   Relationship:

SSN:   Allocation %:

Terms, Notices, and Certifications

Acknowledgment of Receipt: By signing below, the participant certifies receipt of the documents checked above and acknowledges that they have been provided the opportunity to review the Plan Document and Summary Plan Description. Receipt of these materials does not constitute legal or tax advice. Participant should consult personal counsel or tax advisor for individual questions.

Accuracy and Authorization: The participant certifies that the information provided on this Pack is true, correct and complete to the best of their knowledge. The participant authorizes the Plan Administrator and Employer to rely on the information provided herein for purposes of establishing Plan records, making allocations and computing distribution rights.

Vesting and Distribution: The participant acknowledges that vesting schedules and distribution rules are governed by the Plan Document. The participant understands that allocations described in this Pack are subject to Plan terms, applicable vesting, and any required reductions for taxes, liens, or obligations as described in the Plan.

Privacy and Use of Data: The participant consents to use of personal data by the Plan Administrator and Employer for Plan administration, statutory reporting, distribution processing and as otherwise required by law. Document copies will be retained as Plan records.

Administrative Use / Recordkeeping

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