Disability Withdrawal Request 401(k) Plan

1 Disability Withdrawal Request401(k) PlanSTD FDSTDB ][04/07/17)( 98960 -01 WITHDRAWALNO_GRPG 421/][GU22)(/][GP22 DOC ID: 477279085)(Page 1 of 19 Texa$aver 401(k) Plan98960-01 When would I use this form?When I am requesting a Withdrawal due to my Disability or making a change to an existing periodic installment payment due to Disability . If my Withdrawal is for any reason other than Disability or if I am age 59 or older, I would need to complete either the In-Service Withdrawal Request ,if I am still employed with the Employer/Company sponsoring this Plan, or the Separation from Employment/Retirement Withdrawal Request , if I amno longer working for the Employer/Company sponsoring this Information For purposes of this form, the terminology ' Withdrawal ' is the same as 'Distribution'.

2 I may confirm the address that is on file and track the status of this Withdrawal Request by logging into my account on the website at For questions regarding this form, refer to the attached Participant Withdrawal Guide ("Guide"), visit the website at or contactService Provider at 1-800-634-5091. Return Instructions for this form are in Section I. Use black or blue ink when completing this is my personal information?(Continue to the next section after completing.)Account extension, if applicable, identifies fundstransferred to a beneficiary due to participant'sdeath, alternate payee due to divorce or a participantwith multiple ExtensionSocial Security Number or Taxpayer Identification Number(Must provide all 9 digits)Last NameFirst AddressSelect One (Required): Citizen Resident Alien Non-Resident Alien or OtherCountry of Residence (Required - See Guide for IRS FormW-8 BEN information.)

3 //Date of Birth (mm/dd/yyyy)( )Daytime Phone Number( )Alternate Phone NumberBWhat is my reason for this Withdrawal ?(Continue to the next section after completing.) Disability - Plan Administrator approval for this Withdrawal Request is am no longer employed with the employer/company sponsoring this Plan AND my Disability meets the definition of Disability under the from Employment Date (Required): / / Note: My Withdrawal will be subject to an early Withdrawal penalty if I am under age 59 , unless my Disability also meets the InternalRevenue Code ( IRC ) 72(m)(7) definition of Disability or another exception applies (See Guide for definition). If my Disability meets therequirements under IRC 72(m)(7), I can Request my Withdrawal to be reported as exempt from the federal ten percent (10%) earlywithdrawal penalty, by obtaining my physician s signature in 'My Physician s Information and Certification of Disability ' type of Withdrawal and how much am I requesting?

4 100% Withdrawal will be the Maximum Amount Available(Continue to the next section after completing.)Effective Date: (Required if requesting a future dated Withdrawal within the next 180 days. If left blank and Request is in good order, withdrawalwill be processed as soon as administratively feasible.)Payable to Me as a One-time WithdrawalAmount Non-Roth _____% or $_____Contribution Source:_____Amount Roth _____% or $_____Contribution Source:_____Net Amount (The amount I will receive after applicable income taxes and fees are withheld.)Gross Amount (The amount I will receive will be less than the amount requested after applicable income taxes and fees are withheld.)100% Withdrawal With A Portion Payable to Me and the Remaining Balance as a Direct RolloverNet Amount (The amount I will receive after applicable income taxes and fees are withheld.)

5 Gross Amount (The amount I will receive will be less than the amount requested after applicable income taxes and fees are withheld.)Non-RothPayable to Me Amount _____% or $_____Direct Rollover Amount 100 % of the remaining balanceEligible Retirement Plan: 401(a) 401(k) 403(b) Governmental 457(b)Traditional IRA Roth IRA (Taxable event - Subject to ordinary income taxes) 98960 -01 Last NameFirst Security NumberNumberSTD FDSTDB ][04/07/17)( 98960 -01 WITHDRAWALNO_GRPG 421/][GU22)(/][GP22 DOC ID: 477279085)(Page 2 of 19 CWhat type of Withdrawal and how much am I requesting?100% Withdrawal will be the Maximum Amount Available(Continue to the next section after completing.)RothPayable to Me Amount _____% or $_____Direct Rollover Amount 100 % of the remaining balanceEligible Retirement Plan (Must have a designated Roth Account): 401(k) 403(b) Governmental 457(b)Roth IRAR ollover to an IRA or New Employer's Plan as a One-time WithdrawalNon-RothEligible Retirement Plan: 401(a) 401(k) 403(b) Governmental 457(b)Amount _____% or $_____Traditional IRAA mount _____% or $_____Roth IRAA mount _____% or $_____ (Taxable event - Subject to ordinary income taxes)RothEligible Retirement Plan (Must have a designated Roth Account).

6 401(k) 403(b) Governmental 457(b)Amount _____% or $_____Roth IRAA mount _____% or $_____Periodic Installment Payments (Complete the information below.)I am requesting to establish a new Periodic Installment am making a change to an existing Periodic Installment am requesting a one time Withdrawal payable to me of _____% or $ _____ at the same time I am requesting this PeriodicInstallment Amount (The amount I will receive after applicable income taxes and fees are withheld.)Gross Amount (The amount I will receive will be less than the amount requested after applicable income taxes and fees are withheld.)Unless I make a selection below, the payment will be calculated and prorated from all contribution Non-Roth Contribution Sources First (Once the Non-Roth contribution sources are depleted, the payment will continue and will then be proratedbetween all available Roth contribution sources.)

7 ORNon-Roth Contribution Sources Only (The payment will stop once the Non-Roth contribution sources are depleted.)ORRoth Contribution Sources Only (The payment will stop once the Roth contribution sources are depleted.)First Payment Processing Date: _____/_____/_____ (1st - 28th only)Frequency - Select One: Monthly Quarterly Semi-Annually Annually Payment Type - Select One: Amount Certain (Gross Amount Only) $_____ Period Certain (Specific Number of Years) _____Interest Only Payments, Converted to Required Minimum Distribution at age 70 (Must have at least onefixed investment option and attach copy of Birth Certificate or Driver s License)Direct Rollover of Self-Directed Brokerage ("SDB") Account Assets (Complete information below.)

8 Investments will be distributed in shares.)This option is only available if I am 100% vested and requesting a full Withdrawal . I must elect one of the applicable options for the Full Withdrawaltype. In addition, my entire account balance must be available for Withdrawal based on my Withdrawal reason selected in Section B. It is myresponsibility to contact the receiving firm to initiate this rollover. Provide the verified name of the institution, account number and DTC numberof the receiving institution below. Non-RothEligible Retirement Plan Rollover (403(b) Plans cannot accept individual securities)401(a) 401(k) 403(b)457(b) GovernmentalTraditional IRA RolloverRoth IRA Rollover (Subject to ordinary income taxes) RothEligible Retirement Plan Rollover (403(b) Plans cannot accept individual securities) 401(k) 403(b)457(b) GovernmentalRoth IRA Rollover98960-01 Last NameFirst Security NumberNumberSTD FDSTDB ][04/07/17)( 98960 -01 WITHDRAWALNO_GRPG 421/][GU22)(/][GP22 DOC ID: 477279085)(Page 3 of 19 DIf I am requesting a Rollover or Direct Rollover of Self-Directed Brokerage Account Assets,To whom do I want my Withdrawal payable and where should it be sent?

9 (Continue to the next section after completing.)Do not complete if requesting Payable to If I would like to direct Roth earnings to a Rollover payee other thanthe one listed below, I must attach a letter of instruction listing thesame information that is required in this section and must include thetype of payee, my name, social security number, signature and of Trustee/Custodian/Provider (To whom the check is made payable)Name of Trustee/Custodian/Provider (To whom the check is made payable)Mailing AddressMailing Address()()City/State/Zip CodePhone NumberCity/State/Zip CodePhone NumberAccount Number (if available)Account Number (if available)Retirement Plan Name (if applicable)Retirement Plan Name (if applicable)Direct Rollover of All Self-Directed Brokerage Account AssetsNon-RothRothName of Financial InstitutionName of Financial InstitutionMailing AddressMailing Address()()City/State/Zip CodePhone NumberCity/State/Zip CodePhone NumberAccount NumberDTC Number of Receiving InstitutionAccount NumberDTC Number of Receiving InstitutionEHow do I want my Withdrawal delivered?

10 (Continue to the next section after completing.)Select One - Delivery of payment is based on completion of the Withdrawal process, which includesreceipt of a complete Request in good order and additional/required information from my employer. If no option is selected, all transactions will be sent by United States Postal Service ("USPS") regular mail. If I would like to make a change to what I previously selected, I must cross-out and initial the change(s). If I do not initial all changes,all transactions will be sent by USPS regular by USPS Regular Mail Estimated delivery time is 7-10 business days No additional chargeCheck by Express Delivery Estimated delivery time is 1-2 business days A non-refundable charge of up to $ will be deducted, in addition to any Withdrawal fees, for each transaction.