Rollover Retirement Agreement

ROLLOVER RETIREMENT AGREEMENT

This Rollover Retirement Agreement ("Agreement") is made effective as of by and between Participant Name: , residing at ("Participant"), and Receiving Plan Administrator / Custodian: , with principal business address ("Receiving Plan" or "Custodian").

RECITALS

WHEREAS, Participant holds retirement plan assets described as Account/Plan Name: , Account/Identification No.: (collectively, the "Payor Plan Account");

WHEREAS, Participant desires to transfer or roll over all or a portion of the Payor Plan Account to the Receiving Plan in a manner intended to qualify as a rollover under applicable law; and

WHEREAS, the Receiving Plan and its Custodian are willing to accept such transfer on the terms set forth herein and the Payor Plan Administrator is authorized to effect the transfer upon receipt of Participant's authorization.

NOW, THEREFORE, in consideration of the mutual covenants and agreements set forth below, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, the following terms shall have the meanings set forth below:

"Distribution" means the payment, transfer or delivery of funds or other property from the Payor Plan Account that the Participant has requested to be rolled over to the Receiving Plan pursuant to this Agreement.

"Rollover Amount" means the dollar amount or percentage of the Payor Plan Account to be transferred: .

2. AUTHORIZATION AND TRANSFER INSTRUCTIONS

Participant hereby authorizes and directs the Payor Plan Administrator to distribute the Rollover Amount to the Receiving Plan. Participant elects the following method of rollover (select applicable option(s)):

Direct rollover (trustee-to-trustee transfer) Indirect rollover (distribution payable to Participant)

If a direct rollover is selected, the Payor Plan Administrator shall issue transfer by check or electronic transfer payable to the Receiving Plan for benefit of Participant. Receiving Plan Account No.: . Desired transfer date: .

3. WITHHOLDING AND TAX ACKNOWLEDGMENTS

Participant acknowledges that any distribution not directly rolled over may be subject to income tax and, if applicable, required withholding. Participant elects:

Do not withhold federal income tax Withhold as required by law

Participant further certifies under penalties of perjury that Participant believes this rollover is eligible for tax-free rollover treatment under applicable law and that Participant will timely comply with any requirements applicable to indirect rollovers, including redepositing distributed amounts within the statutory period.

4. REPRESENTATIONS AND WARRANTIES

Participant represents and warrants that Participant is entitled to receive the Distribution, that there are no outstanding claims, liens, or restrictions that would prevent the transfer, and that all information provided in this Agreement is true, complete, and correct. Participant agrees to notify the Receiving Plan promptly if any representation becomes untrue prior to transfer.

5. INDEMNIFICATION AND LIMITATION OF LIABILITY

Participant shall indemnify and hold harmless the Receiving Plan, Custodian, Payor Plan Administrator, and their respective directors, officers, employees and agents from and against any losses, liabilities, claims, damages, costs and expenses (including reasonable attorneys' fees) arising out of Participant's breach of any representation, warranty or covenant in this Agreement or Participant's failure to comply with tax or rollover requirements. The Receiving Plan and Custodian shall not be liable for any taxes assessed on the Distribution except to the extent such liability arises from the Receiving Plan's gross negligence or willful misconduct.

6. FEES AND EXPENSES

Any administrative fees, transfer fees, or other expenses charged in connection with the rollover shall be borne as provided in the Receiving Plan's fee schedule, which Participant acknowledges receiving or is otherwise familiar with. Participant authorizes payment of fees from transferred assets if required by the Receiving Plan or Custodian.

7. NOTICES

Notices under this Agreement shall be sent to the addresses set forth below (or to such other address as a party may designate by written notice):

8. AMENDMENT; WAIVER; COUNTERPARTS

This Agreement may be amended only by a written instrument signed by both parties. No waiver of any provision shall be effective unless in writing and signed by the party granting the waiver. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Agreement shall be governed by and construed in accordance with the laws of the state specified below without regard to its conflict of laws principles. Governing law state: .

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written agreements and understandings. If any provision of this Agreement is held invalid or unenforceable, the remainder of the Agreement shall remain in full force and effect.

10. MISCELLANEOUS

If any party is required to bring suit to enforce the terms of this Agreement, the prevailing party shall be entitled to recover reasonable attorneys' fees and costs. Headings are inserted for convenience only and shall not affect interpretation.

SIGNATURES

The parties, intending to be legally bound, have executed this Agreement as of the dates set forth below.

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