Tier One/Tier Two/Individual Account Program (IAP ...

1 form #459-364 (8/10/2017) SL3 IIM Code: 2163 Page 1 of 6 Section A: Applicant information11410 SW 68th Parkway, Tigard OR 97223 Mailing Address PO Box 23700, Tigard OR 97281-3700 Toll free 888-320-7377 fax 503-598-0561 Website C: Spousal consent and notarized signatureSection B: retirement options (Select a survivorship or a non-survivorship option.) Survivorship Options (Name a benefi ciary.) Non-Survivorship Options Option 2 Option 3 Lump-Sum Option 2 Lump-Sum Option 3 Option 1 Refund Annuity 15-Year Certain Lump-Sum Option 1 Total Lump-Sum Option 2A Option 3A Lump-Sum Option 2A Lump-Sum Option 3 ABenefi ciary nameBenefi ciary Social Security numberBenefi ciary date of birth (mm/dd/yyyy)Relationship to youTier One/Tier Two/Individual Account Program (IAP) retirement ApplicationMy PERS retirement date is the fi rst day of MonthYearFirst nameMILast namePERS number (optional)Mailing address (street or PO box)

2 CountrySocial Security number*CityStateZipDate of birth (mm/dd/yyyy)Gender Male FemaleHome phone number Work phone numberCell phone numberEmail*Providing your Social Security number (SSN) is mandatory, and PERS is authorized to request it under provisions of the Internal Revenue code. It will primarily be used to comply with mandatory IRS reporting. It could also be used for confi rmation purposes or recovery of overpaid funds. In compliance with the Americans with Disabilities Act, PERS will provide help filling out this form upon request. You may request help by calling 888-320-7377 or TTY acknowledgmentMust sign in the presence of a notary.

3 As of my effective retirement date, I am married. As of my effective retirement date, I am consent (Required if married.)Must sign in the presence of a notary. I consent to the option and benefi ciary my spouse s signature DateSpouse s signature DateNotary PublicNotary PublicState of County ofState of County ofApplicant nameSpouse nameSigned before me on this dateSigned before me on this dateBy (notary s signature)By (notary s signature)Print and sign this form . This application is not valid unless you sign and date each section of the form you #459-364 (8/10/2017) SL3 IIM Code: 2163 Page 2 of 6 First nameMILast nameSocial Security numberSection D: Citizenship and residencySection E: Variable electionIf you have a variable Account , do you want to continue to participate in the Variable Annuity after retirement ?

4 This may cause your benefi t to increase or decrease annually. (Select only one.) Ye s NoSection F: Police offi cer and fi refi ghter unitsI would like my police offi cer and fi refi ghter units benefi t effective: On my selected retirement date in Section A to be paid over _____ months. Number Delayed until _____ 1, _____ to be paid over _____ months. Month Year NumberSection G: Working after retirement acknowledgmentBy signing below I acknowledge that I have received and read the PERS document entitled Working After retirement Information for Tier One/Tier Two Retirees.

5 Applicant s signatureDate Applicant s signatureDateSection H: Acknowledgment of Receipt of Federal Tax Information Disclosure and federal tax 30-day waiver I have received and read the Federal Tax Information Disclosure. Applicant s signatureDateAre you either a citizen or resident alien? (Select only one.) Ye s No (Complete a W-8 BEN form .)Select one: I am a resident of the state of Oregon; therefore, payments made to me as a result of this benefi t application will be subject to Oregon personal income tax. I am not a resident of the state of Oregon; therefore, payments made to me as a result of this benefi t application will not be subject to Oregon personal income hereby declare that the above statement is true to the best of my knowledge and belief, and I understand it is subject to penalty for #459-364 (8/10/2017) SL3 IIM Code: 2163 Page 3 of 6 First nameMILast nameSocial Security numberSection I: Tier One/Tier Two lump-sum distribution installmentsYou can receive your lump-sum in one, two, three, four, or fi ve annual payments.

6 Check the appropriate box below to indicate how many installments you want to receive, and then enter the percentage you want for each installment. The total must equal 100 percent. (Select only one.) 100% Two installments: Three installments: Four installments: Five installments: 1st % 1st% 1st % 1st % 2nd % 2nd % 2nd % 2nd %% 3rd % 3rd % 3rd %% 4th % 4th %% 5th %%Section J: Tier One/Tier Two lump-sum payment distribution Select only one. Important: You must provide either a percentage or dollar amount below.

7 Send installment(s) directly to me. Send my installment(s) to an IRA. My IRA is a traditional IRA Roth IRA. Roll over _____ percent of my payment. Roll over $ _____ of my my installment to the custodian or trustee of my IRA:Custodian/trustee nameAccount numberPhone numberAddressCityStateZip Send my installment(s) to another eligible employer plan or deferred compensation plan. Roll over _____ percent of my payment. Roll over $ _____ of my : If you are rolling over funds to an eligible employer plan or deferred compensation plan other than the Oregon Savings Growth Plan (OSGP) you must have an authorized representative of the plan complete the Direct Transfer Rollover Acceptance form .

8 form #459-364 (8/10/2017) SL3 IIM Code: 2163 Page 4 of 6 Section K: Benefi ciary for Tier One/Tier Two non-survivorship optionsFirst nameMILast nameSocial Security numberSpecifi c benefi ciary #3 Primary benefi ciary [If living; otherwise, to #3 alternate benefi ciary(ies).] #3 Name of person or charitySocial Security #Date of birthRelationshipAddress of person or charityPercentageAlternate benefi ciary(ies): How many alternate benefi ciaries do you want to designate? _____(Benefi t will go to those named below if #3 specifi c benefi ciary is deceased.) 3aName of person or charitySocial Security #Date of birthRelationshipAddress of person or charityPercentage 3bName of person or charitySocial Security #Date of birthRelationshipAddress of person or charityPercentage If any of the above named primary benefi ciaries predecease me and I have not named an alternate benefi ciary, I want the portion of my benefi t that was designated to that benefi ciary shared equally among the remaining primary benefi ciaries living at my c benefi ciary #1 Primary benefi ciary [If living; otherwise, to #1 alternate benefi ciary(ies).]

9 ] #1 Name of person or charitySocial Security #Date of birthRelationshipAddress of person or charityPercentageAlternate benefi ciary(ies): How many alternate benefi ciaries do you want to designate? _____(Benefi t will go to those named below if #1 specifi c benefi ciary is deceased.) 1aName of person or charitySocial Security #Date of birthRelationshipAddress of person or charityPercentage1bName of person or charitySocial Security #Date of birthRelationshipAddress of person or charityPercentageSpecifi c benefi ciary #2 Primary benefi ciary [If living; otherwise, to #2 alternate benefi ciary(ies).] #2 Name of person or charitySocial Security #Date of birthRelationshipAddress of person or charityPercentageAlternate benefi ciary(ies): How many alternate benefi ciaries do you want to designate?

10 _____ (Benefi t will go to those named below if #2 specifi c benefi ciary is deceased.) 2aName of person or charitySocial Security #Date of birthRelationshipAddress of person or charityPercentage2bName of person or charitySocial Security #Date of birthRelationshipAddress of person or charityPercentage I elect to use the standard benefi ciary designation. I elect to use the specifi c designation of benefi ciary. (You may designate more than one benefi ciary and the percentage of the Account distributed to each. The total percentage must equal 100 percent. Complete the table below. Add additional benefi ciaries on a separate sheet of paper.)