DISTRIBUTION REQUEST FORM - T. Rowe Price

1 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)

2 Determined by the plan administrator on the basis of written determination by the Social Security Administration that disability payments under the Social Security Act have been approved) In-Service Withdrawal Plan Termination Date _____/_____/_____ METHOD OF DISBURSEMENT Distribute 100% of my vested account balance as a cash DISTRIBUTION to me at the address above (this is a taxable event) Roll over 100% of my vested account balance to the account indicated below Distribute ____% of my vested account balance as a cash DISTRIBUTION at the address above, and roll over ____% to the account indicated below Distribute either ____% of my vested account balance or $_____ to me at the address above Type of Rollover Account.

3 IRA ____ QUALIFIED PLAN ____ ROTH IRA ____ Check Payable to (Financial Institution/Plan Trustee) _____ Account Name / Retirement Plan Name _____ Account Number _____ Address _____City _____ State _____ ZIP _____ If your qualified plan rollover includes Roth assets, will your new plan trustee accept these assets? Yes No SHIPPING METHOD Regular Mail ____ Two Day ____ Overnight ____ Carrier Name and Billing #_____ (If requesting two-day or overnight shipping, carrier information must be provided.)

4 If carrier information is not provided, your REQUEST will be sent via United States Postal Service First-Class Mail.) 2015-AX-6759 2/15 OIM11-DISA participant AUTHORIZATION I understand that this DISTRIBUTION will be taken from all money sources and pro rata from all available investment options and will be reported to the Internal Revenue Service and the state of my residence, if applicable, as taxable income as appropriate. The address on this form will determine my state of residence for state withholding purposes.

5 I also understand that the DISTRIBUTION will be subject to income taxes unless I roll over the DISTRIBUTION amount to another retirement account. Any DISTRIBUTION eligible for rollover that is greater than $200 is subject to 20% mandatory federal income tax withholding unless I directly roll over the amount of the DISTRIBUTION to another retirement account. I further understand that, if I receive this DISTRIBUTION prior to age 59 , the DISTRIBUTION may be subject to a 10% early withdrawal penalty.

6 State taxes will be withheld at the state s mandatory withholding rate, if applicable. Withhold federal income tax at ____% of the total DISTRIBUTION (20% or greater). P I have read the Your Rollover options document attached to this form and REQUEST a DISTRIBUTION from the retirement plan designated above. If this form is submitted within the 30-day notice window, I recognize and wish to waive the 30-day notice requirement and have my DISTRIBUTION processed immediately. participant Signature _____ Date _____ PLAN ADMINISTRATOR AUTHORIZATION AND VESTING VERIFICATION (to be completed by the plan administrator) As plan administrator, I hereby certify that the vesting percentage for this participant is equal to ____%.

7 I authorize the DISTRIBUTION to be processed in the manner indicated above. Plan Administrator Signature _____Date _____ Print Name _____ 2015-AX-6759 2/15 OIM11-DISA1 This document combines two Rollover options notices. The first notice describes the rollover and other tax rules that apply to payments from the Plan that are not from a designated Roth account. The second notice (beginning at page 6) describes the rollover and other tax rules that apply to payments from the Plan that are from a designated Roth account (if applicable).

8 For Payments Not From a Designated Roth AccountYOUR ROLLOVER OPTIONSYou are receiving this notice because all or a portion of a payment you are receiving from your employer s retirement plan (the Plan ) is eligible to be rolled over to an IRA or an employer plan. This notice is intended to help you decide whether to do such a notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth account (a type of account with special tax rules in some employer plans).

9 If you also receive a payment from a designated Roth account in the Plan, you will be provided a different notice for that payment, and the Plan administrator or the payor will tell you the amount that is being paid from each that apply to most payments from a plan are described in the General Information About Rollovers section. Special rules that only apply in certain circumstances are described in the Special Rules and options INFORMATION ABOUT ROLLOVERS How can a rollover affect my taxes?You will be taxed on a payment from the Plan if you do not roll it over.

10 If you are under age 59 and do not do a rollover, you will also have to pay a 10% additional income tax on early distributions (unless an exception applies). However, if you do a rollover, you will not have to pay tax until you receive payments later and the 10% additional income tax will not apply if those payments are made after you are age 59 (or if an exception applies).Where may I roll over the payment?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.