DISTRIBUTION REQUEST FORM - T. Rowe Price

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

You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity) or an employer plan (a tax- qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept the rollover.

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