Fill and Sign the Waiver Qualified Form

WAIVER OF QUALIFIED JOINT AND SURVIVOR ANNUITY Submit this form within 90 days prior to the beginning payment date of the participant’s initial distribution or loan request. Participant Information Employer Plan Number Employer Plan Name             Full Name of Participant       Social Security Number Daytime Phone Number             Participant’s Authorized Signature I have made an election for distribution of benefits in a form other than a Qualified Joint and Survivor Annuity. The plan administrator has provided me with a written explanation of the effect of this election, my right to waive the joint and survivor payment form and the financial effect of selecting an alternate payment form. I understand that this election is revocable up until the beginning distribution date, and anytime thereafter for assets that are not yet distributed. I hereby waive the distribution of plan benefits in the form of a Qualified Joint and Survivor Annuity (“QJSA”). I hereby waive the QJSA 30-day notice period under Internal Revenue Code sections 401(a)(11) and 417(a)(7) _________ Signature of Participant Date Consent of Spouse I,       [insert your name], am the spouse of       [insert name of Participant]. I understand that I have the right to have my spouse’s retirement benefits in the form of a Qualified Joint Survivor Annuity (“QJSA”), and I agree to waive that right. I understand that by signing this agreement, I may receive less money than I would have received under the QJSA payment form and I may receive nothing after my spouse dies depending on the payment form that my spouse chooses. I understand that by signing this waiver, my spouse can choose any retirement benefit form that is allowed by the Plan without telling me and without getting my agreement. I also understand. I also understand that my spouse can change the retirement benefit form selected at any time without telling me and without getting my agreement. I understand that I can limit my spouse’s choice to a particular retirement benefit form and that I am waiving that right. I understand that I do not have sign this agreement, then my spouse and I will receive payments from the plan in the form of QJSA. I hereby consent to my spouse’s waiver of the QJSA 30-day notice period under Internal Revenue Code sections 401(a)(11) and 417(a)(7). I have executed this consent this       day of       , 20       , which is no more than 90 days from the beginning payment date requested by my spouse. _________ Signature of Spouse of Participant Date Witnessed by: Employer’s Plan Representative Signature of Spouse witnessed this       day of       , day of, 20       _________ Employer’s Plan representative Notary Public Subscribed and sworn to before me this       day of       , 20       . ____________________________________ My commission expires       Notary Public