1 Account. SIMPLE IRA Distribution Form. Owner information. distribution For transfer incident to divorce see Sections 3 and 6.

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1 1 Account Owner information 2 Request Please type or print carefully. If your address is different from what is currently shown on your account, your signature must be guaranteed in Section 13. for distribution For transfer incident to divorce see Sections 3 and 6. First name MI Last Address City State ZIP Social Security number Account number Fund(s) I am a U.S. citizen or resident alien: Yes No (If no, see Section 10) For distributions regarding: Phone number ( ) Date of birth Required minimum distribution (RMD) Please complete the RMD form available by calling 800/ Death Please complete the Beneficiary Claim Form available by calling 800/ Transfer to new Custodian or Trustee Please obtain the appropriate form from the New Custodian or Trustee. Rollover to another Qualified plan, 403(b) or eligible 457(b) plan Please obtain the appropriate form from the New Custodian or Trustee. Normal (age or older) Early I am under the age of and not taking substantially equal payments. I understand I will be subject to a 25% penalty with the IRS if distributions are taken within the first two years of my participation in the plan. After two years, this penalty is 10%; unless an IRC 72(t) exception applies. The two year period begins on the first day contributions are made to your SIMPLE IRA. Is this distribution within the first two years? Yes No What month/date/year was the first contribution made to your SIMPLE IRA? Exceptions to the penalty include catastrophic medical expenses, health insurance premiums after unemployment, higher education expenses, and first-home purchase (up to $10,000). Early (exception applies) I am under the age of and substantially equal payments will be made at least annually for 5 years or until I reach the age of , whichever is longer. I am using the following calculation method: Life Expectancy (Complete Section 4) Annuitization* (Complete Section 3) Amortization* (Complete Section 3) * does not perform this calculation. month/day/year Disability Please provide documentation that you have been or will be disabled for a 12-month period or longer. Date you first became disabled 1

2 3 Distribution payments Please complete only one option. One time distribution (see Section 5 for payment instructions) Fund Percentage Dollar Share amount amount amount OR Installment payments (see Section 5 for payment instructions) Fund Percentage Dollar Share Number of amount amount amount withdrawals until the account is closed Please select installment payment frequency (all distributions will occur annually unless stated otherwise): Monthly Quarterly Semi-annually Annually Make the first distribution in (month) (year) Make distributions on (insert a day of the month between the 6th and the 28th) 4 Life expectancy payments See Section 5 for payment instructions. This section does not apply to required minimum distributions (RMD). Please use the RMD form. If you checked the Early (exception applies) box in Section 2 and you want Capital Bank and Trust (CB&T) to calculate your substantially equal periodic payments, please complete this section. Check only one box for payment option. I. Over my lifetime. My date of birth II. Over my lifetime and the lifetime of my designated primary beneficiary. My date of birth My beneficiary s date of birth Please select life expectancy payment frequency (all distributions will occur annually unless stated otherwise): Monthly Quarterly Semi-annually Annually Make the first distribution in (month) (year) Make distributions on (insert a day of the month between the 6th and the 28th) 2

3 5 Payment instructions 6 Request for a transfer incident to divorce 7 Special payorder of check If rolling over your monies to another Trustee or Custodian, please provide the name and address of Trustee or Custodian. 8 Federal income tax (Does not apply to non-resident aliens.) Direct Deposit is available only for installment or life expectancy payments. If direct deposit is selected, a signature guarantee may be required in Section 13. I would like CB&T to make payments in the following way: By check (see Section 7 if the check is being sent to a special payorder) By direct deposit to my bank account number. Withdrawals will be deposited into your bank account within three business days following each withdrawal date. (Please tape a voided check or a savings account deposit slip to Section 11.) In shares (in kind) to my existing non-retirement account number In shares (in kind) to a new non-retirement account (attach account application) Direct rollover in shares to my existing Retirement plan account number Direct rollover in shares to my new Retirement plan account (attach account application). Transfer % or $ or shares of the account balance in my SIMPLE IRA. Make the transfer as a result of divorce or legal separation: In shares (in kind) to awarded spouse s existing IRA or retirement plan account number In shares (in kind) to a new IRA for awarded spouse (attach application) By check to my spouse s IRA or retirement plan trustee (see Section 7) This request must be accompanied by a: Copy of the divorce decree or decree of separate maintenance, with original certification by court clerk Guaranteed signature of IRA owner (see Section 13) Completed IRA application from the awarded spouse (if applicable) If the SIMPLE IRA has been established for less than 2 years, the assets must be transferred to a SIMPLE IRA for the awarded spouse. Complete this section if the check is to be made payable to someone other than the registered shareholder or mailed to an address other than the address of record. If this section is completed, a signature guarantee is required in Section 13. Name MI Last (Trustee or Custodian, if applicable) Address City State ZIP Account number If this check is a result of a transfer incident to divorce, check must be payable to the trustee or custodian of awarded spouse s IRA or retirement plan. Federal law requires us to withhold income tax equal to 10% of the distribution unless you elect otherwise. If you DO NOT elect otherwise, we must withhold tax. If we withhold federal tax, state tax may also be required. (See State Income Tax below). You may want more than 10% withheld, because if you do not have enough withheld, you might need to pay estimated taxes. Insufficient withholding or underpayment of estimated tax may result in IRS penalties. Please check one box to indicate your federal withholding. If you take your distributions in periodic withdrawals, the you make now will apply until you change it. If no is made, the trustee must withhold taxes at the required rate. I DO NOT want federal taxes withheld from this distribution. Please furnish a U.S. residence address (physical or street) for this option: Withhold for federal taxes: $ or % 3

4 9 State income tax (Does not apply to nonresident aliens) If federal withholding is applied to your distributions, state income tax withholding may also apply. State income tax withholding will be calculated in accordance with the regulations of your state of residence. Please contact your tax advisor or state agency to determine your state s withholding requirements or for specific questions regarding your personal tax situation. My state of residence for tax purposes is:. Residents of IA, LA, MA, ME and MS 1 will have state taxes withheld when federal withholding applies. Residents of CA 2, DE, GA, KS, NC, OK, OR and VT will have state taxes withheld when federal withholding applies unless otherwise elected. These residents may elect to have state withholding while electing out of federal withholding. If no is made, the trustee is required to withhold taxes at the required rate. I DO NOT want state income tax withheld. In addition to the standard state tax withholding amount, I would also like an additional $ withheld (do not indicate a percentage). 1 Residents of MS are subject to mandatory state withholding when federal withholding is applied to early distributions. 2 The state income tax withholding calculation for CA is based on a percentage of the federal withholding amount and not a percentage of the gross distribution. 10 Nonresident alien tax If you are not a citizen or resident alien of the U.S. you may claim the tax treaty rate for your country of residence by attaching a completed Form W-8BEN with an original signature. Without a properly completed Form W-8 BEN, CB&T is required to withhold tax at the maximum rate of 30%. If you need to obtain a blank Form W-8BEN, please contact at (714) Bank information Please attach an unsigned, voided check or deposit slip preprinted with the bank account registration. Please tape: Unsigned, voided check for checking account OR Deposit slip for savings account 4

5 12 Authorization I direct CB&T to make distributions from my account in the manner I have indicated and I assume sole responsibility for the tax consequences of the withholding. I certify that the above information and attached documentation is accurate and that I am entitled to receive the payments for which I have applied. In consideration of CB&T acting on such instructions and processing such transactions, or should I not be entitled to all or any part of the payments for which I have applied, I agree to hold harmless and indemnify CB&T, any of its affiliates or mutual funds managed by such affiliates, each of their respective directors, trustees, officers, employees and agents from any losses, expenses, costs or liability (including attorney fees) that may be incurred as a result of CB&T acting on such instructions. In addition, if direct deposit payments are requested, I understand that this payment may be terminated by me at any time by telephone or written notification to CB&T. The termination request will be effective as soon as CB&T has had reasonable time to act upon it. Account Owner (please print) Signature of Account Owner Date 13 Signature guarantee GUARANTOR: Affix signature guarantee stamp here GUARANTOR: Affix signature guarantee stamp here 14 Service centers Use this map to determine where to mail this form. (If you live outside the U.S., please mail to the Western Service Center.) A signature guarantee is not required for any redemption of $75, or less, provided the redemption check is made payable to the registered shareholder and is mailed to the address of record. If your redemption request is greater than $75,000.00, made payable to someone other than the registered shareholder, directly deposited to a bank account in the name of someone in addition to or other than the registered shareholder or being mailed to an address other than the address of record, a signature guarantee will be required. In the case of direct deposit, the signature guarantee of all bank account owners must be guaranteed. See Section 5. The signature must be guaranteed by an "eligible guarantor" including a bank or savings and loan association that is federally insured or a member firm of the National Association of Securities Dealers, Inc. The guarantee must be in the form of a stamp; typewritten and handwritten guarantees will not be accepted unless they are accompanied by a raised corporate seal and specifically say Signature Guaranteed. A signature guarantee will also be accepted from: (1) a foreign bank whose guarantee is guaranteed by a United States correspondent bank, or (2) a United States Embassy or Consulate in the case of United States citizens, or (3) a base commanding officer or a member of the JAG Corps in the case of United States military personnel. A notarization by a notary public is not acceptable. Western Service Center P.O. Box Santa Ana, CA Western Central Service Center P.O. Box San Antonio, TX East Central Service Center P.O. Box 6164 Indianapolis, IN Eastern Service Center P.O. Box 2560 Norfolk, VA Lit. No. IRA Litho in USA CGD/PDF/ Distributors, Inc.

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