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ROLLOVER IN - Deferred Compensation

Participant_____Last Name First Social Security Number (last 4)I have the following pre-tax retirement savings account: _____ ID/Account Number_____ _____Investment/Brokerage Name (Transferring Plan) Phone Number_____ Address _____City, State & ZipCheck type of plan: 457(b) 403(b) 401(k) 401(a) Traditional ROLLOVER IRA Investment Option % of Funds Ohio DC Stable Value Option 100%l I elect to execute a ROLLOVER of the market value of the account named above to an account administered by the Ohio Deferred Compensation Program (Ohio DC), an IRC 457(b) plan, and agree to follow the ROLLOVER rules of both I hereby request that a check for the account less any surrender charges be issued by the transferring plan, payable to Ohio Deferred Compensation .

Investment Option % of Funds Ohio DC Stable Value Option 100% l I elect to execute a rollover of the market value of the account named above to an account administered by the Ohio Deferred Compensation Program (Ohio DC), an IRC 457 plan, and agree to follow the rollover rules of both plans.

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