DISTRIBUTION REQUEST FORM

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DISTRIBUTION REQUEST form If you wish to take a DISTRIBUTION or roll over your account to another retirement account , please complete: 1. Participant Information 2. Type of DISTRIBUTION 3. Method of disbursement 4. Participant Authorization 5. plan Administrator Authorization and Vesting Verification Fax the completed form to 816-218-0424. PARTICIPANT INFORMATION plan Name ________________________________________ _______ plan ID___________________________________ First Name and Middle Initial _________________________________ Last Name ________________________________ Social Security Number ____________________________ Daytime Phone Number_______________________________ Evening Phone Number _______________________________ Address ___________________________________ City ___________________ State ________ ZIP___________ TYPE OF DISTRIBUTION Termination of Employment Date ______/______/______ retirement Date ______/______/______ Disability Date

If you wish to take a distribution or roll over your account to another retirement account, please complete: 1. Participant Information 2. Type of Distribution 3. Method of Disbursement 4. Participant Authorization 5. Plan Administrator Authorization and Vesting Verification Fax the completed form to 816-218-0424. PARTICIPANT INFORMATION

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