o I hereby request a total SURRENDER of my contract/certificate (please enclose).

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1 Distributin Request Frm Prtective Life Insurance Cmpany (PLICO/"the Cmpany") Prtective Life and Annuity Insurance Cmpany (PLAIC/"the Cmpany") Cntract Owner Custmer Service Office: Cntract Annuitant P.O. Bx 1928 Cntract Number Birmingham, AL Daytime Phne Number Plan Type Sectin 1: Distributin Amunt Distributins may be subject t incme tax and if made befre age 59½ may be subject t an additinal 10% IRS penalty. The cmpany suggests that yu cnsult an attrney, accuntant, r tax advisr fr infrmatin prir t requesting a distributin. Full distributin will result in terminatin f cntract. Check One: I hereby request a ttal SURRENDER f my cntract/certificate (please enclse). I/we certify that this cntract has been lst r destryed. If it is fund later, I/we agree t surrender it t the cmpany withut claim. Partial distributin (check ne belw) must meet minimum withdrawal amunt requirements fr the prduct, except RMD's. Check One: Grss withdrawal $ : Deduct any withdrawal charges and tax withhlding frm the amunt requested. Net withdrawal $ : Issue check fr amunt requested. Deduct any withdrawal charges and tax withhlding separately. Interest nly: Distribute all interest earnings frm the fixed accunt. Will be prcessed as a grss withdrawal. Penalty free amunt: Withdraw maximum amunt withut incurring surrender charges. Will be prcessed as a grss withdrawal. Required Minimum distributin (RMD): Will be calculated using a unifrm distributin perid that is based n IRS tables. If yu have a spuse as sle beneficiary wh is mre than 10 years yunger, yur distributins will be based upn the jint life expectancy f yu and yur spuse. Des nt apply t nn-qualified r ROTH IRA cntracts. The withdrawal will be taken pr-rata frm all existing Subaccunts / Fixed Accunts. Withdrawals frm Guaranteed Perid Accunts may incur a market value adjustment. Sectin 2: Reasn fr Distributin (Nt applicable t IRA and Nn-Qualified cntracts) Participant has attained age 59½ Severance f emplyment after participant has attained age 55 - Date f severance / / Severance f emplyment - Date f severance / / Disability. By checking this bx, I certify that I am unable t engage in substantial gainful emplyment due t an impairment that is f a cntinuing r permanent nature as defined under Internal Revenue Cde Sectin 72(m)(7). Financial hardship. (cmplete Sectin 4) 3771-GEN-06 (11/13) Page 1 f 4

2 Sectin 3: Vesting Instructins (fr 401(a), 401(k), 403(b), 457, ORP & ARP Plans) This sectin must be cmpleted by the Plan Administratr. Are emplyer cntributins vested? Yes N If n, indicate the percentage amunt vested: % Sectin 4: Financial Hardship Distributin Under 403(b) Plans (Nt Applicable t IRA and Nn-Qualified Cntracts) Fr 403(b) and 401(a) plans, earnings accumulated after December 31, 1988 may nt be distributed under financial hardship. Hardship withdrawals are available accrding t Internal Revenue Cde Sectins 401(k)(2) and related federal tax regulatins, and must be made t satisfy an immediate heavy financial need. Financial Hardship Need: (Please check ne) Medical expenses incurred by me, my spuse r dependents Tuitin, related educatinal fees, rm and bard expenses fr the next 12 mnths f pst-secndary educatin fr me, my spuse r dependents Purchase f my principal residence (excluding mrtgage payments) Preventing freclsure n my principal residence r evictin frm my principal residence Available Resurces Prir t requesting a financial hardship distributin, yu must use resurces that are reasnably available t yu t satisfy the financial hardship need, including assets f yur spuse and minr children. Indicate if yu have used the fllwing resurces t satisfy yur financial hardship need: Liquidatin f assets Cessatin f elective cntributins r emplyee cntributins under the plan Lans r distributins frm any plan maintained by the emplyer r any ther emplyer Cmmercial Lans Reimbursement r cmpensatin by insurance r therwise Yes N If yu checked "N" t any f the abve, yu are nt eligible fr a financial hardship distributin, since yu have nt used resurces that are reasnably available t yu. The cmpany reserves the right t require dcumentatin t supprt yur request fr a financial hardship distributin. Certificatin I certify that all the infrmatin I have prvided is accurate. I als certify that the amunt f the distributin I have requested des nt exceed the amunt necessary t relieve my financial hardship need and that I have used all resurces that are reasnably available t me t satisfy the financial need. Participant Name Participant Signature Date Sectin 5: Mailing Instructins Check One: Address f recrd Other (indicate address belw)* This is a permanent address change I wish t use Electrnic Funds Transfers (Direct Depsit). I authrize the cmpany t crrect electrnically any verpayments f errneus credits made t my accunt. Please attach a vided check t this request. Please nte - Express mail will nt be delivered t a PO Bx Street Address City State Zip Cde * Ntary Signature Required - ONLY when requesting funds be sent t a different address r different bank accunt than n file. See signature sectin GEN-06 (11/13) Page 2 f 4

3 Sectin 6: Express Mail Please withdraw $15.00 frm my accunt and express mail the check t the address indicated in the Mailing Instructins sectin. I understand that this cnstitutes a distributin frm my accunt and the cmpany will withhld the apprpriate amunt fr federal incme taxes (if withhlding is elected). Express fees may change based n mailing address but currently will nt exceed $ Sectin 7: Special Instructins Sectin 8: Tax Withhlding fr IRA's, Nn-Qualified Accunts and Required Minimum Distributins Only The Cmpany is required t withhld ten percent (10%) f the federally taxable amunt n distributins ther than eligible rllver distributins, unless yu elect nt t have withhlding apply. If yu elect nt t have withhlding apply, yu may be respnsible fr payment f estimated tax and yu may incur tax penalties if the sum f the amunt withheld and yur estimated tax payments are nt sufficient. Yur electin may be revked at any time and will remain in effect until revked. If yu make n electin, 10% will be withheld frm the distributin. Federal Withhlding: Withhld 10% D Nt Withhld Specify % r $ State Withhlding: Withhld as Required by State D Nt Withhld Specify % r $ Sectin 9: Tax Withhlding fr 403(b), ORP, ARP, 401(a), 401(k), and 457 Plans Only The Cmpany is required t withhld twenty percent (20%) f the federally taxable amunt n all distributins unless the distributin is deemed a "Direct Rllver". State withhlding may als be required. If yu elect t have the cmpany withhld mre than 20%, please indicate this belw. A participant may elect a direct rllver by instructing the Cmpany t make distributins payable t the spnsr f an IRA r eligible emplyer retirement plan. Federal Withhlding: Specify % r $ (cannt be less than 20%) State Withhlding: Withhld as Required by State D Nt Withhld Specify % r $ Sectin 10: Additinal 10% Tax if Yu Are Under Age 59½ If yu receive a distributin befre yu reach age 59½ and yu d nt rll ver the payment t an eligible retirement plan, then in additin t the regular incme tax, yu may have t pay an extra tax equal t 10% f the taxable prtin f the payment. The additinal 10% tax des nt apply t yur payment if it is (1) paid t yu because yu separate frm service with yur emplyer during r after the year yu reach age 55, (2) paid because yu retire due t disability, (3) used t pay certain medical expenses, (4) paid t yu as part f a Qualified Dmestic Relatins Order, r (5) paid t yu as a crrective distributin. Beginning in 1998, the additinal 10% tax may be waived fr distributins frm IRAs fr: (1) qualified higher educatin expenses, (2) health insurance premiums, r (3) qualified first-time hmebuyer distributins. See IRS Frm 5329 fr mre infrmatin n the additinal 10% tax GEN-06 (11/13) Page 3 f 4

4 Sectin 11: Signatures By signing belw, the Owner(s), Participant and Plan Administratr hereby certify that the infrmatin prvided in this request is cmplete and accurate, and understand that the Cmpany will prcess this request accrding t the infrmatin prvided. By signing belw, the Participant acknwledges that he/she has been prvided with the Special Tax Ntice and affirmatively elects t prcess the distributin as requested. The special tax ntice nly applies t 403(b) and 457 plans. This affirmative electin will waive the 30 day perid t which the Participant is entitle t cnsider this distributin. Name f Owner / Participant Owner Signature / Participant Signature Date Name f Jint Owner Jint Owner Signature Date Name f Plan Administratr (if any) Plan Administratr Signature Date Agreed by: (Assignee Signature, if any) Agreed by: (Irrevcable Beneficiary Signature, if any) Date Date If the Owner r Participant (if ther than Owner) resides in a Cmmunity Prperty State, we recmmend that the spuse f the Owner r Participant (as applicable) jin in signing this frm. This is fr the prtectin f bth parties. Please sign and date belw. Spuse Signature Date Spusal Cnsent fr ERISA plans: I hereby cnsent t the request as stated abve. I understand that a spuse is guaranteed certain rights t assets in this retirement accunt by federal law and that these include the right t a pre-retirement survivr's annuity and a jint and survivr annuity and that these rights culd be diminished by chance t the cntract. Participant has n legal spuse. Spuse Signature Date Witnessed by: (Plan Administratr r Ntary Public Signature) Title Date 3771-GEN-06 (11/13) Page 4 f 4

5 Special Tax Ntice Regarding Plan Payments Safe Harbr Explanatin fr Plans Qualified Under Sectin 403(b) Tax Sheltered Annuities and Gvernmental 457(b) Plans This ntice explains hw yu can cntinue t defer federal incme tax n yur retirement savings in the The Cmpany sectin 403(b) annuity r yur gvernmental sectin 457(b) plan (the "Plan") and cntains imprtant infrmatin yu will need befre yu decide hw t receive yur Plan benefits. Generally, mst 403(b) annuities will have a Payr and gvernmental 457(b) plans will have a Plan Administratr. This ntice is prvided t yu by The Cmpany (yur "Payr") because all r part f the payment that yu will sn receive frm the Plan may be eligible fr rllver by yu, the Payr, r yur Plan Administratr t a traditinal IRA r an eligible emplyer plan. A rllver is a payment by yu r the Plan Administratr f all r part f yur benefit t anther plan r IRA that allws yu t cntinue t pstpne taxatin f that benefit until it is paid t yu. Yur payment cannt be rlled ver t a Rth IRA, a SIMPLE IRA, r a Cverdell Educatin Savings Accunt (frmerly knwn as an educatin IRA). An "eligible emplyer plan" includes a plan qualified under sectin 401(a) f the Internal Revenue Cde, including a 401(k) plan, prfit sharing plan, defined benefit plan, stck bnus plan, and mney purchase plan; a sectin 403(a) annuity plan; a sectin 403(b) tax-sheltered annuity; and an eligible sectin 457(b) plan maintained by a gvernmental emplyer (gvernmental 457 plan). An eligible emplyer plan is nt legally required t accept a rllver. Befre yu decide t rll ver yur payment t anther emplyer plan, yu shuld find ut whether the plan accepts rllvers and, if s, the types f distributins it accepts as a rllver. Yu shuld als find ut abut any dcuments that are required t be cmpleted befre the receiving plan will accept a rllver. Even if a plan accepts rllvers, it might nt accept rllvers f certain types f distributins, such as after-tax amunts. If this is the case, and yur distributin includes after-tax amunts, yu may wish instead t rll yur distributin ver t a traditinal IRA r split yur rllver amunt between the emplyer plan in which yu will participate and a traditinal IRA. If an emplyer plan accepts yur rllver, the plan may restrict subsequent distributins f the rllver amunt r may require yur spuse's cnsent fr any subsequent distributin. A subsequent distributin frm the plan that accepts yur rllver may als be subject t different tax treatment than distributins frm this Plan. Check with the administratr f the plan that is t receive yur rllver prir t making the rllver. If yu have additinal questins after reading this ntice, yu can cntact yur Payr at r yur Plan Administratr. Summary There are tw ways yu may be able t receive a Plan payment that is eligible fr rllver: 1) certain payments can be made directly t a traditinal IRA that yu establish r t an eligible emplyer plan that will accept it and hld it fr yur benefit ("DIRECT ROLLOVER"), r 2) the payment can be PAID TO YOU. If yu chse a DIRECT ROLLOVER: Yur payment will nt be taxed in the current year and n incme tax will be withheld. Yu chse whether yur payment will be made directly t yur traditinal IRA r t an eligible emplyer plan that accepts yur rllver. Yur payment cannt be rlled ver t a Rth IRA, a SIMPLE IRA, r a Cverdell Educatin Savings Accunt because these are nt traditinal IRAs. Yur payment will be taxed later when yu take it ut f the traditinal IRA r the eligible emplyer plan. Depending n the type f plan, the later distributin may be subject t different tax treatment than it wuld be if yu received a taxable distributin frm this Plan. If yu chse t have a Plan payment that is eligible fr rllver PAID TO YOU: Yu will receive nly 80% f the taxable amunt f payment, because the Plan Administratr r Payr is required t withhld 20% f the payment and send it t the IRS as incme tax withhlding t be credited against yur taxes. The taxable amunt f yur payment will be taxed in the current year unless yu rll it ver. Yu can rllver all r part f the payment by paying it t yur traditinal IRA r t an eligible emplyer plan that accepts yur rllver within 60 days after yu receive the payment. The amunt rlled ver will nt be taxed until yu take it ut f the traditinal IRA r the eligible emplyer plan. If yu want t rll ver 100% f the payment t a traditinal IRA r an emplyer plan, yu must find ther mney t replace the 20% f the taxable prtin that was withheld. If yu rll ver nly the 80% that yu received, yu will be taxed n the 20% that was withheld and that is nt rlled ver. Yur Right t Waive the 30-Day Ntice Perid. Generally, neither a direct rllver nr a payment can be made frm the Plan until at least 30 days after yur receipt f this ntice. Thus, after receiving this ntice, yu have at least 30 days t cnsider whether r nt t have yur withdrawal directly rll ver. If yu d nt wish t wait until this 30-day ntice perid ends befre yur electin is prcessed, yu may waive the ntice perid by making an affirmative electin indicating whether r nt yu wish t make a direct rllver. Yur withdrawal will then be prcessed in accrdance with yur electins as sn as practical after it is received by the Plan Administratr r Payr. SPECIAL TAX (11/13) Page 1 f 4

6 I. Payments That Can And Cannt Be Rlled Over II. Payments frm the Plan may be "eligible rllver distributins." This means they can be rlled ver t a traditinal IRA r t anther eligible emplyer plan that accepts rllvers. Payments frm a plan cannt be rlled ver t a Rth IRA, a SIMPLE IRA, r a Cverdell Educatin Savings Accunt. Yur Plan Administratr r Payr shuld be able t tell yu what prtin f yur payment is an eligible rllver distributin. After-Tax Cntributins. If yu made after-tax cntributins t the Plan, these cntributins may be rlled int either a traditinal IRA r t certain emplyer plans that accept rllvers f the after-tax cntributins. The fllwing rules apply: a) Rllver int a Traditinal IRA. Yu can rllver yur after-tax cntributins t a traditinal IRA either directly r indirectly. Yur Plan Administratr r Payr shuld be able t tell yu hw much f yur payment is the taxable prtin and hw much is the after-tax prtin. If yu rllver after-tax cntributins t a traditinal IRA, it is yur respnsibility t keep track f, and reprt t the Service n the applicable frms, the amunt f these after-tax cntributins. This will enable the nntaxable amunt f any future distributins frm the traditinal IRA t be determined. Once yu rllver yur after-tax cntributins t a traditinal IRA, thse amunts CANNOT later be rlled ver t an emplyer plan. Yu can als rllver after-tax cntributins frm a sectin 403(b) tax-sheltered annuity t anther sectin 403(b) tax-sheltered annuity using a direct rllver if the ther tax-sheltered annuity prvides separate accunting fr amunts rlled ver, including separate accunting fr the after-tax emplyee cntributins and earnings n thse cntributins. Yu CANNOT rllver after-tax cntributins t a gvernmental 457 plan. If yu want t rllver yur after-tax cntributins t an emplyer plan that accepts these rllvers, yu cannt have the after-tax cntributins paid t yu first. Yu must instruct the Plan Administratr r Payr f this Plan t make a direct rllver n yur behalf. Als, yu cannt first rllver after-tax cntributins t a traditinal IRA and then rll that amunt int an emplyer plan. Payments Spread Over Lng Perids Yu cannt rll ver a payment if it is part f a series f equal (r almst equal) payments that are made at least nce a year and that will last fr: yur lifetime (r a perid measured by yur life expectancy), r yur lifetime and yur beneficiary's lifetime (r a perid measured by yur jint life expectancies), r a perid f 10 years r mre. Required Minimum Distributins. Beginning in the year yu reach age 70 1/2 r retire, whichever is later, a certain prtin f yur payment cannt be rlled ver because it is a "required minimum payment" that must be paid t yu. Hardship Distributin r Distributins Due t an Unfreseeable Emergency. A hardship distributin r a distributin due t an unfreseeable emergency cannt be rlled ver. Crrective Distributins. A distributin that is made t crrect a failed nndiscriminatin test r because legal limits n certain cntributins were exceeded cannt be rlled ver. Lans Treated as Distributins. The amunt f a plan lan that becmes a taxable deemed distributin because f a default cannt be rlled ver. Hwever, a lan ffset amunt is eligible fr rllver, as discussed in Part III belw. Ask the Plan Administratr r Payr f yur Plan if distributin f yur lan qualifies fr rllver treatment. The payr f this Plan shuld be able t tell yu if yur payment includes amunts which cannt be rlled ver. Direct Rllver A DIRECT ROLLOVER is a direct payment f the amunt f yur Plan benefits t a traditinal IRA r an eligible emplyer plan that will accept it. Yu can chse a DIRECT ROLLOVER f all r any prtin f yur payment that is an eligible rllver distributin, as described in Part I abve. Yu are nt taxed n any taxable prtin f yur payment fr which yu chse a DIRECT ROLLOVER until yu later take it ut f the traditinal IRA r eligible emplyer plan. In additin, n incme tax withhlding is required fr any taxable prtin f yur Plan benefits fr which yu chse a DIRECT ROLLOVER. Yur Plan might nt let yu chse a DIRECT ROLLOVER if yur distributins fr the year are less than $200. Direct Rllver t a Traditinal IRA. Yu can pen a traditinal IRA t receive the direct rllver. If yu chse t have yur payment made directly t a traditinal IRA, cntact an IRA spnsr t find ut hw t have yur payment made in a direct rllver t an IRA. If yu are unsure f hw t invest yur mney, yu can temprarily establish a traditinal IRA t receive the payment. Hwever, in chsing a traditinal IRA, yu may wish t make sure that the traditinal IRA yu chse will allw yu t mve all r a part f yur payment t anther traditinal IRA at a later date, withut penalties r ther limitatins. See IRS Publicatin 590, Individual Retirement Arrangements, fr mre infrmatin n traditinal IRAs (including limits n hw ften yu can rllver between IRAs). SPECIAL TAX (11/13) Page 2 f 4

7 Direct Rllver t a Plan. If yu are emplyed by a new emplyer that has an eligible emplyer plan, and yu want a direct rllver t that plan, ask the plan administratr f that plan whether it will accept yur rllver. An eligible emplyer plan is nt legally required t accept a rllver. Even if yur new emplyer's plan des nt accept a rllver, yu can chse a DIRECT ROLLOVER t a traditinal IRA. If the emplyer plan accepts yur rllver, the plan may prvide restrictins n the circumstances under which yu may later receive a distributin f the rllver amunt r may require spusal cnsent t any subsequent distributin. Check with the Plan Administratr r Payr befre making yur decisin. Direct Rllver f a Series f Payments. If yu receive a payment that can be rlled ver t a traditinal IRA r an eligible emplyer plan that will accept it, and it is paid in a series f payments fr less than 10 years, yur chice t make r nt make a DIRECT ROLLOVER fr a payment will apply t all later payments in the series until yu change yur electin. Yu are free t change yur electin fr any later payment in the series. Change in Tax Treatment Resulting frm a DIRECT ROLLOVER. The tax treatment f any payment frm the eligible emplyer plan r traditinal IRA receiving yur DIRECT ROLLOVER might be different than if yu received yur benefit in a taxable distributin directly frm the Plan. See the sectins belw entitled "Additinal 10% Tax May Apply t Certain Distributins." III. Payment Paid T Yu If yur payment can be rlled ver (see Part I abve) and the payment is made t yu in cash, it is subject t 20% federal incme tax withhlding n the taxable prtin (state tax withhlding may als apply). The payment is taxed in the year yu receive it unless, within 60 days, yu rll it ver t a traditinal IRA r an eligible emplyer plan that accepts rllvers. If yu d nt rll it ver, special tax rules may apply. Incme Tax Withhlding: Mandatry Withhlding. If any prtin f yur payment can be rlled ver under Part I abve and yu d nt elect t make a DIRECT ROLLOVER, the Plan is required by law t withhld 20% f the taxable amunt. This amunt is sent t the IRS as federal incme tax withhlding. Fr example, if yu can rllver a taxable payment f $10,000, nly $8,000 will be paid t yu because the Plan must withhld $2,000 as incme tax. Hwever, when yu prepare yur incme tax return fr the year, unless yu make a rllver within 60 days (see "Sixty-Day Rllver Optin" belw), yu must reprt the full $10,000 as a taxable payment frm the plan. Yu must reprt the $2,000 as tax withheld, and it will be credited against any incme tax yu we fr the year. There will be n incme tax withhlding if yur payments fr the year are less than $200. Vluntary Withhlding. If any prtin f yur payment is taxable but cannt be rlled ver under Part I abve, the mandatry withhlding rules described abve d nt apply. Cmplete the apprpriate sectin n the applicable request frm. Sixty-Day Rllver Optin. If yu receive a payment that can be rlled ver under Part I abve, yu can still decide t rllver all r part f it t a traditinal IRA r t an eligible emplyer plan that accepts rllvers. If yu decide t rllver, yu must cntribute the amunt f the payment yu received t a traditinal IRA r eligible emplyer plan within 60 days after yu receive the payment. The prtin f yur payment that is rlled ver will nt be taxed until yu take it ut f the traditinal IRA r the eligible emplyer plan. Yu can rllver up t 100% f yur payment that can be rlled ver under Part I abve, including an amunt equal t the 20% f the taxable prtin that was withheld. If yu chse t rll ver 100%, yu must find ther mney within the 60-day perid t cntribute t the traditinal IRA r the eligible emplyer plan, t replace the 20% that was withheld. On the ther hand, if yu rllver nly the 80% f the taxable prtin that yu received, yu will be taxed n the 20% that was withheld. Example: The taxable prtin f yur payment that can be rlled ver under Part I abve is $10,000, and yu chse t have it paid t yu. Yu will receive $8,000, and $2,000 will be sent t the IRS as incme tax withhlding. Within 60 days after receiving the $8,000, yu may rllver the entire $10,000 t a traditinal IRA r an emplyer plan. T d this, yu rllver the $8,000 yu received frm the Plan, and yu will have t find $2,000 frm ther surces (yur savings, a lan, etc.). In this case, the entire $10,000 is nt taxed until yu take it ut f the traditinal IRA r emplyer plan. If yu rllver the entire $10,000, when yu file yur incme tax return yu may get a refund f the $2,000 withheld. If, n the ther hand yu rllver nly $8,000, the $2,000 yu did nt rll ver is taxed in the year it was withheld. When yu file yur incme tax return yu may get a refund f part f the $2,000 withheld. (Hwever, any refund is likely t be larger if yu rllver the $10,000.) Additinal 10% Tax If yu are Under Age 59 1/2 frm a sectin 403(b) annuity. If yu receive a payment befre yu reach age 59 1/2 and yu d nt rll it ver, then, in additin t the regular incme tax, yu may have t pay an extra tax equal t 10% f the taxable prtin f the payment. The additinal 10% tax generally des nt apply t (1) payments that are paid t yu because yu sever emplyment with yur emplyer during r after the year yu reach age 55, (2) payments that are paid because yu retire due t disability, (3) payments that are paid t yu as equal (r almst equal) payments ver yur life r life expectancy (r yu and yur beneficiary's lives r life expectancies), r (4) payments that are paid directly t the gvernment t satisfy a federal tax levy, (5) payments that are paid t an alternate payee under a qualified dmestic relatins rder, r (6) payments that d nt exceed the amunt f yur deductible medical expenses. See IRS Frm 5329 fr mre infrmatin n the additinal 10% tax. SPECIAL TAX (11/13) Page 3 f 4

8 The additinal 10% tax will nt apply t distributins frm a gvernmental 457 plan, except t the extent the distributin is attributable t an amunt yu rlled ver t the gvernmental 457 plan (adjusted fr investment returns) frm anther type f eligible emplyer plan r IRA. Any amunt rlled ver frm a gvernmental 457 plan t anther type f eligible emplyer plan r t a traditinal IRA will becme subject t the additinal 10% tax if it is distributed t yu befre yu reach age 59 1/2, unless ne f the exceptins applies. Repayment f Plan Lans. If yur emplyment ends and yu have an utstanding lan frm yur Plan, yur Plan Administratr r Payr may reduce (r "ffset") yur balance in the Plan by the amunt f the lan yu have nt repaid. The amunt f yur lan ffset is treated as a distributin t yu at the time f the ffset and will be taxed unless yu rllver an amunt equal t the amunt f yur lan ffset t anther qualified emplyer plan r a traditinal IRA within 60 days f the date f the ffset. If the amunt f yur lan ffset is the nly amunt yu receive r are treated as having received, n amunt will be withheld frm it. If yu receive ther payments f cash r prperty frm the Plan, the 20% withhlding amunt will be based n the entire amunt paid t yu, including the amunt f the lan ffset. The amunt withheld will be limited t the amunt f ther cash r prperty paid t yu. The amunt f a defaulted plan lan that is a taxable deemed distributin cannt be rlled ver. IV. Surviving Spuses, Alternate Payees, and Other Beneficiaries In general, the rules summarized abve that apply t payments t emplyees als apply t payments t surviving spuses f emplyees and t spuses r frmer spuses wh are "alternate payees." Yu are an alternate payee if yur interest in the Plan results frm a "qualified dmestic relatins rder," which is an rder issued by a curt, usually in cnnectin with a divrce r legal separatin. If yu are a surviving spuse r an alternate payee, yu may chse t have a payment that can be rlled ver, as described in Part I abve, paid in a DIRECT ROLLOVER t a traditinal IRA r t an eligible emplyer plan r paid t yu. If yu have the payment paid t yu, yu keep it r rll it ver yurself t a traditinal IRA r t an eligible emplyer plan. Thus, yu have the same chices as the emplyee. If yu are a beneficiary ther than a surviving spuse r an alternate payee, yu cannt chse a direct rllver, and yu cannt rllver the payment yurself. If yu are a surviving spuse, an alternate payee, r anther beneficiary, yur payment is nt subject t the additinal 10% tax described in Part III abve, even if yu are yunger than age 59 1/2. SPECIAL TAX (11/13) Page 4 f 4

Special Tax Notice Regarding 403(b) (TSA) Distributions

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