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 the basis of written determination by the Social Security Administration that disability payments under the Social Security)

• The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse).

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