Rollover/Recontribution Request ROLLOVER

1 ROLLOVER /Recontribution RequestSection C- Investment Election ( participant Completes)Please select either 1 or 2. 1. My ROLLOVER contribution or return of a previous coronavirus - related distribution or Qualified Birth or Adoption distribution will be invested in my current investment elections in the plan. If I have not completed an Enrollment Form under this Plan, my ROLLOVER contribution will be invested in the Plan s default investment option. I understand it is my responsibility to provide investment and/ or exchange instructions through my Employer; by accessing my account online at or by calling Empower Retirement s Customer Service Center at My ROLLOVER contribution or return of a previous coronavirus - related distribution or Qualified Birth or Adoption distribution will be invested in accordance with my investment elections below.

2 (must be whole percentages that total 100%) Note: This option cannot be used if you are currently investing in an Asset Allocation Model or to select a A - Plan Information (Plan Administrator completes)Section B - participant Information ( participant completes)* Legal AddressStateCityPlan ContactParticipant NameDate of BirthPlan NamePlan IDUse this form to Request a ROLLOVER or return of a previous coronavirus - related distribution or Qualified Birth or Adoption distribution , into your 401(k) plan administered by Empower Retirement. Please read Section G - Important Information before completing this form. You must already be enrolled in your Employer s Plan at Empower Retirement before submitting this form.

3 This form may not be used for changes to your investment elections. Your current Plan Administrator will need to verify that you are eligible to make a ROLLOVER contribution and that the amount to be rolled into the Plan is an eligible ROLLOVER contribution under the terms of the Plan and the Internal Revenue Code. See your Plan Administrator for more information. If the ROLLOVER contribution is allowed and if you have not already done so, contact your prior Plan Administrator or IRA provider to initiate the ROLLOVER distribution process. Return this form and ROLLOVER contribution check, if applicable, or return of a previous coronavirus - related distribution or Qualified Birth or Adoption distribution to your current Plan Administrator.

4 Your check will be deposited and the ROLLOVER contribution or return of a previous coronavirus - related distribution or Qualified Birth or Adoption distribution will be allocated to your account once it is approved and received by Empower Retirement. This form will be valid for 90 days from the date of receipt at Empower Retirement. Please note, Empower Retirement cannot process this form until it is received in good order. Please see the Important Information Section for the definition of "Good Order".Total 100%RS-41456-05 Rev Page 1 of 5 Investment 1%Investment 6%Investment 2%Investment 7%Investment 3%Investment 8%Investment 4%Investment 9%Investment 5%Investment 10%F MGender:Daytime Phone NumberSSNZip CodeDaytime Phone Call Empower Retirement s Customer Service Center 1-800-854-0647 Fax 1-800-220-2913 Online ROLLOVERNote: If you do not make investment elections, if the elections are incomplete, or if the percentages listed do not total 100%, the entire ROLLOVER amount or return of a previous coronavirus - related distribution or Qualified Birth or Adoption distribution , will be invested in your current investment elections in the plan.

5 If you do not have investment elections on file, the ROLLOVER or return of a previous coronavirus - related distribution or Qualified Birth or Adoption distribution will be invested in the Plan's default investment option. *All future mailings will be sent to your Legal Address unless changed by you or your Employer and/or Plan Administrator, as applicable, as described under "Stale Address" in the Important Information section. _____ _____ participant Signature Date(4) If this is a 60-day (indirect) ROLLOVER , I certify that this ROLLOVER is being completed within 60 days from receipt or, if it is over 60 days since my receipt of the distribution from the paying plan or financial institution, I have provided certification to the plan sponsor that the funds being rolled over qualify for a waiver from the 60-day requirement and that any self-certification letter required has been provided to the plan sponsor and a copy kept with my own tax records.

6 ( participant should review the information in Section G if they are depositing an indirect ROLLOVER , which also refers to an IRS website with more detailed information). Indirect ROLLOVER payments must be made in the form of employer check, a certified or cashier's check, or money order. Your check should be made payable to Plan Name FBO participant Name ( , ABC 401(k) Plan FBO John Smith)As a former participant in the above-referenced retirement plan or as owner of the above-referenced IRA, I confirm that: (1) the prior plan is either a Traditional IRA (non-Roth) or an eligible retirement plan which qualifies this contribution as an eligible ROLLOVER ; (2) the prior plan or IRA has satisfied such requirements as the Plan may have established for the purpose of reasonably concluding the eligibility for its acceptance of the ROLLOVER contribution amount under the Plan.

7 And (3) I understand that these ROLLOVER contributions, once deposited in the Plan, will be subject to all provisions of the Plan, including all distribution D - ROLLOVER Information (Plan Administrator completes)Amount of ROLLOVER contribution check $401(a) plan (including 401(k), money purchase, profit sharing, defined benefit plans)403(b) planGovernmental 457(b) plan (special requirements may apply - see your tax advisor) Traditional IRA (non Roth) - the amount rolled over consists entirely of pre-tax contributions and earningsThe ROLLOVER represents proceeds from my deceased spouse's retirement ROLLOVER represents a distribution payable to me as a spouse (or former spouse) alternate payee as a result of a : The amount you ROLLOVER must represent a ROLLOVER from an eligible retirement plan or IRA.

8 Note: If this section is incomplete, all amounts received will be considered pre-tax contributions and earnings. Information provided by a prior institution on a check stub will override any information listed in this section. Source of the ROLLOVER :Prior Plan or Account Name:Prior Provider:Indicate whether this ROLLOVER contribution is from an IRA or eligible retirement plan (indicate the type of plan).Other, State Type:Spousal Beneficiary ROLLOVER Information (complete if applicable)Traditional After-tax or Roth ROLLOVER Information (complete if applicable) Traditional After-tax ROLLOVER (only permitted as a direct ROLLOVER from an eligible retirement plan)$ of the ROLLOVER represents after tax employee contributions ( cost basis )$ of the ROLLOVER represents after tax earnings (if there is a loss, indicate with a minus ( - ) sign)Roth After-tax ROLLOVER (only permitted from an eligible retirement plan)$ of the ROLLOVER represents Roth After-tax contributions ( cost basis ).

9 Calendar Year the first Roth contribution was made to distributing plan was 20$ of the ROLLOVER represents Roth earnings (if there is a loss, indicate with a minus ( - ) sign)Note: Cost basis and earnings will be separately accounted for within your ROLLOVER account(s) unless other instructions are provided in an attachment. This is required to ensure that Roth basis and earnings are accounted for separately from the non-Roth portions of the E - participant Request and Signature Page 2 of 5(5) If this is a return of funds received from a coronavirus related distribution as outlined in the CARES Act, I certify that these funds were distributed to me within the past three years.

10 I understand that it is solely my responsibility for determining my eligibility for this transaction under the CARES Act and for all related tax consequences.(6) If I am repaying a Qualified Birth or Adoption distribution , I certify that I am eligible to make a recontribution to the plan and that I previously received a QBAD in an amount no greater than the amount I am repaying with this form plus any other QBAD repayments I have made previously. I understand that it is solely my responsibility for determining my eligibility to make this repayment and for all related tax consequences. Note: Plan Sponsors may choose whether to use this participant Request and Signature section in order to obtain the participant 's confirmation.