Employee Withdrawal Options

EMPLOYEE WITHDRAWAL OPTIONS

Use this form to elect disposition of final compensation and retirement plan assets following separation from employment. Complete all applicable sections, sign and return to Human Resources. Employee Name: Employee ID:

Personal Information

Position Information

Employment Start Date: Separation Date:

Employment History (Most Recent)

Dates Employed: From to

Employment History (Prior)

Dates Employed: From to

Education

Graduation Date:

References (Professional)

Phone: Email:

Phone: Email:

Phone: Email:

Withdrawal Options — Retirement Plan & Final Compensation

I elect the following disposition for my employer-sponsored retirement plan account(s) and final pay. I understand that certain elections may have tax consequences and that cash distributions may be subject to mandatory tax withholding and early withdrawal penalties where applicable. Check only ONE primary option for retirement assets and complete related fields.

Leave funds in plan until eligible for distribution or plan-specified date

Cash lump-sum distribution (subject to mandatory tax withholding and possible penalties) Amount requested:

Direct rollover to another qualified plan or IRA (trustee-to-trustee transfer)

Periodic installment payments (provide proposed schedule)

Partial distribution — Amount:

Tax Withholding & Acknowledgements

I acknowledge that distributions that are not direct rollovers may be subject to federal and state tax withholding and may be subject to an additional early withdrawal penalty under applicable tax law. I elect the following withholding instructions (if applicable).

Apply mandatory federal withholding as required by law

Withhold additional federal tax:

Apply state tax withholding where applicable

Final Compensation — Payment Method

Select method for payment of final wages, accrued vacation, and other final compensation:

Paper check mailed to home address on file

Direct deposit to existing payroll account on file

Benefit Continuation & Other Elections

Health insurance and other employer-sponsored benefits may be eligible for continuation. Select below if you wish to receive continuation election forms.

I elect to receive continuation coverage election information and intend to elect continuation if eligible

I decline continuation coverage and understand I may lose coverage

Legal Disclosures

At-Will Employment: Nothing in this form alters the at-will nature of employment where applicable. Either the employee or the employer retains the right to terminate employment at any time, with or without cause, unless expressly modified by a separate written agreement signed by authorized representatives.

Equal Opportunity: The employer maintains an equal opportunity employment policy and prohibits discrimination or retaliation in employment decisions.

Employee Certification & Authorization

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that elections regarding retirement account distributions are generally irrevocable once processed and that I am responsible for understanding tax consequences of my election. I authorize the employer and plan administrators to act on my election and, where necessary, to obtain and release information to effect direct rollovers or other transfers.

Authorization to Contact Prior Employers and Conduct Background Checks:

I authorize the employer and its agents to contact prior employers and references listed herein to verify employment history and to obtain other information reasonably related to my employment and separation administration. I also authorize consumer and/or criminal background checks if required to effect administration of final pay or benefits.

Consent to Electronic Delivery: Where permitted, I consent to receive plan documents, tax forms, and notices in electronic form and acknowledge it is my responsibility to provide and maintain current contact information.

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