Plan Information Participant Information - …

1 Products and financial services provided byAmerican United Life Insurance Company a OneAmerica companyOne American Square, Box 6011 Indianapolis, IN 46206-60111-800-249-6269In-Service Distribution RequestPage 1 of 4R-19305 1/27/14 plan InformationPlan Number Division (if applicable) plan NameParticipant Information First Name Last Name M FSocial Security (or Taxpayer ID)

2 Number Sex Date of BirthStreet AddressStreet Address City StateZip CodeWork PersonalTelephone Number (including area code) E-mail AddressDistribution Information Full Withdrawal Check this box to request distribution of your entire vested account balance, less any applicable tax withholdingand/or fees. Certain money types may be restricted based on the provisions of the plan .

3 Partial Withdrawal Check this box to request a specific amount partial withdrawal. Specify the amount in the space provided. Pleaseprovide the gross amount(before any applicable tax withholding and/or fees). Amount Requested % or $ Note:Any applicable tax withholding and/or fees will reduce the distribution amount either paid to you or rolledover into another eligible retirement plan . The amount requested will be distributed and withdrawn proportionatelyfrom all investments and requested sources eligible for in-service withdrawal. If both a percentage and a dollaramount are provided, the distribution will be based on the percentage indicated.

4 If a percentage is listed and specificwithdrawal sources are selected in the Employer Information and Authorization section of this form, thepercentage of the specified sources will be withdrawn. hardship Withdrawal Check this box to request a hardship distribution. Note:In order to take hardship distribution your employer must confirm hardship availability under the plan , youmust have a qualifying expense, and (a) The distribution cannot be in excess of the amount of your immediate and heavy financial need. (b) You must have obtained all distributions, other than hardship distributions, and all nontaxable loans currentlyavailable under all plans that your employer maintains; and (c) You will be suspended from making salary deferrals for at least six (6) months after your receipt of the your Summary plan Description (SPD) or plan representative for additional Information .

5 Documentation of yourqualifying expense may be requested as evidence for the plan s this form to request a distribution from your account in a qualified retirement plan because of a financial hardship ,attainment of age 59 1/2, attainment of age 70 1/2, or any other type of in-service withdrawal permitted by your 2 of 4R-19305 1/27/14 Distribution Information (continued)Tax Withholding Federal Tax Withholding The Internal Revenue Service requires income tax withholding of 10% for hardshipdistributions unless you elect otherwise. All other benefit distributions require 20% income tax withholding unlessyou are directly rolling over to another qualified retirement plan or traditional IRA.

6 You can choose to have a higherpercentage withheld. If your election below conflicts with these rules, the required amount will be withheld. State Tax Withholding If you live in a state that requires state tax withholding if federal tax is withheld, then we willautomatically withhold the mandatory amount for state taxes. You can choose to have a higher percentage withheld;however, an election of a lower percentage will be ignored. Do you want federal tax withholding from your distribution?No Yes Please withhold:% Do you want state tax withholding from your distribution?No Yes Please withhold:%Payment Information Lump Sum Distribution By selecting this option, you are requesting a taxable distribution.

7 Rollover Select this box if you are requesting that your distribution be moved from one American United Life InsuranceCompany (AUL) contract to another AUL contract or to another financial institution. Type of Rollover (please check onebox, if applicable) Internal Rollover (from one AUL contract to another AUL contract) AUL Account Number: External Rollover (to another financial institution)Important! If you selected External Rollover , please provide the following:Account Type:Another Qualified plan Traditional IRA Roth IRAName of Institution Account NumberMailing Address City StateZip CodeTelephone NumberExtensionFinancial Institution / Bank InformationIf this section is not complete or your employer requests to have a check mailed directly to them.

8 A check will be mailedinstead of an ACH electronic funds transfer. For a Lump Sum Distribution this is your bank Information . For a Rollover,this is the receiving company s bank Institution / Bank Information Checking Account Savings AccountFinancial Institution / Bank NameCity / State / ZIPMust be 9 digits and cannot begin with 4, 5, 8, or 9 Financial Institution / Bank Routing (ABA) Number Account number cannot exceed 17 digitsFinancial Institution / Bank Account Number Please obtain your routing number from a check if Checking Account was indicated above.

9 If Savings Account was indicated,please obtain your routing number from a deposit slip. Routing numbers cannot begin with a 4, 5, 8 or 9 . Please contact yourbank for verification of your routing (ABA) number if it begins with one of these SignatureI certify that the Information provided is complete and accurate to the best of my knowledge and that I received acopy of the Special Tax Notice Regarding Payments (P-15021) from my employer. I further certify, if applicable, thatthe qualified retirement plan or IRA named to receive my distribution(s) is an eligible plan for purposes of receivingdirect to applicable laws, regulations, and any applicable plan document, I am entitled to the benefit requested forthe reason checked below.

10 I authorize AUL to deposit all contract payments due me into the account identified in thesection above. I discharge AUL from any further liability for any payments deposited to my account under thisauthorization. I also authorize AUL to initiate corrections, if necessary, to any amounts credited to my account in such payments shall be returned to AUL by the Financial Institution if funds are available in my account or shall bereturned to AUL by me, my estate or my heirs if the funds in my account are not sufficient to make the requiredcorrection. I understand that AUL may terminate its electronic fund transfer at any time and for any reason, and maymake contract payments by check Note to the Participant :You have a right to consider the decision of whether or not to elect a direct rolloverfor at least 30 days after receipt of the Special Tax Notice Regarding Payments.