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 ______/______/______ (Disability as determined by the plan administrator on)

• Payments made under a qualified domestic relations order (QDRO) • Payments up to the amount of your deductible medical expenses • Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more than 179 days

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