Social Security Number Daytime Phone Number Evening Phone Number. D. What is the approximate amount of your rollover contribution? $,,.

Transcription

1 DTE Energy Company Savings and Stock Ownership Plan 1 Rollover Application Your Personal Information (Please use ink and print in capital letters) Social Security Number Daytime Phone Number Evening Phone Number Last Name First Name MI Address City State Zip Address 2 Rollover Information Please answer the following questions regarding your rollover contribution: A. Please check plan type: 401(a)/401(k) 403(b) 457(b) Rollover IRA Traditional IRA DTE Defined Benefit Pension Plan B. Does your rollover contain any after-tax contributions? yes no Please see below for more information on eligible rollover contributions. C. Does your rollover contain any Roth 401(k) contributions? yes no D. What is the approximate amount of your rollover contribution? $,,. E. Prior employer plan name: (if applicable) The plan will accept rollovers from the following sources: Contributions from a prior employer's plan from the following sources: After-tax contributions Roth 401(k) contributions An eligible rollover distribution from a prior employer's plan of the following type: Qualified 401(a) plan, including a 401(k) plan 457(b) deferred compensation plan of a government entity 403(b) plan (sometimes called a tax sheltered annuity) DTE-sponsored defined benefit pension plan A rollover IRA (one that contains a distribution from a prior employer's plan) A traditional IRA (but not a Roth IRA or a nondeductible IRA) For specific questions concerning whether or not your distribution qualifies as an eligible rollover distribution, please contact your former plan administrator. Continued on the next page

2 Rollover Application 3 Your Investment Choices You must indicate below how you want your Rollover contributions invested. Choose one or any combination of the choices below. The percentages must be whole numbers, not fractions, and total 100. You can create your own portfolio from any combination of the available funds. I am currently enrolled in the Professional Management Program. I understand that my rollover contribution will be managed through the program. Information about the Professional Management Program, including how the program works and applicable fees, is enclosed in this guide. I am not enrolled in the Professional Management Program. Please invest my rollover contribution as indicated below. (You can choose one or any combination of the choices below. The percentages must be in whole numbers, not fractions or decimals, and total 100.) Investment Options All Contributions Investment Options All Contributions Cash Alternatives Money Market Fund T Rowe Price Retirement 2030 Trust-T4 T Rowe Price Retirement 2035 Trust-T4 Bonds US Bond Market Index Fund US Intermediate Bond Index Fund US Active Bond Fund Asset Allocation Real Asset Fund T Rowe Price Retirement Balanced Trust-T4 T Rowe Price Retirement 2005 Trust-T4 T Rowe Price Retirement 2010 Trust-T4 T Rowe Price Retirement 2015 Trust-T4 Tactical Asset Allocation Fund T Rowe Price Retirement 2020 Trust-T4 T Rowe Price Retirement 2025 Trust-T4 T Rowe Price Retirement 2040 Trust-T4 T Rowe Price Retirement 2045 Trust-T4 T Rowe Price Retirement 2050 Trust-T4 Stocks US Active Large Capitalization Value Equity US Large Capitalization Equity Index Fund US Active Large Capitalization Growth Equity US Equity Completion Index Fund US Active Small/Mid Capitalization Equity International Stock Index Fund International Active Equity DTE Energy Company Stock Fund 100 Check instructions The check for your rollover must be a certified check or cashier's check, or a check drawn on a financial institution. Write the last 4 digits of your Social Security number on the check. The check should be made payable as follows: Trustee for DTE Energy Company Savings and Stock Ownership Plan FBO (print your name) Send your check, Rollover Application and Rollover Certification to: Empower Retirement P.O. Box Kansas City, MO

3 Rollover Application You may also send them by overnight mail to the following address: Empower Retirement at Outlook Street, Overland Park, KS Call Empower at if you have questions about this process. Representatives are available to help you weekdays between 7 a.m. and 8 p.m. Central time. The TTY number for those with a hearing impairment is Visit us at 4 Your Signature I certify that the information provided above is accurate. I understand that I am permitted to direct the investment of my accounts in the plan, as outlined in Section 404(c) of ERISA. I acknowledge that I have received and reviewed the information in my rollover kit about my investment choices and have had an opportunity to freely choose how my accounts are invested. I understand and agree that, under Section 404(c), my employer and other plan fiduciaries will not be liable for the results of my investment directions. d and agree that, under Section 404(c), my employer and other plan fiduciaries will not be liable for the results of my investment directions. All funds rolled into DTE Energy Company Savings and Stock Ownership Plan are subject to the terms of DTE Energy Company Savings and Stock Ownership Plan. X Your Signature For more complete information about any of the mutual funds available within the retirement plan, please call Investors should carefully consider the investment objectives, risks, charges and expenses of the funds. Please carefully read the prospectus, which contains this and other important information, before you invest or send money. An investment in a money market fund is not insured or guaranteed by the FDIC or any other government agency. Although money market funds strive to preserve the value of the investment at $1.00 per share, it is possible to lose money by investing in a money market fund. Core securities, when offered, are offered through GWFS Equities, Inc. and/or other broker dealers. GWFS Equities, Inc., Member FINRA/SIPC, is a wholly owned subsidiary of Great-West Life & Annuity Insurance Company. Advised Assets Group, LLC (AAG) uses Financial Engines Advisors L.L.C. (FEA) to provide sub-advisory services. AAG is a federally registered investment adviser and wholly owned subsidiary of Great-West Life & Annuity Insurance Company (GWL&A). FEA is a federally registered investment adviser and wholly-owned subsidiary of Financial Engines, Inc. More information can be found at Financial Engines, Inc. is an independent company that is not affiliated with Great-West Financial Retirement Plan Services, LLC, AAG, its parent company GWL&A, or any other affiliated companies and/or subsidiaries. Financial Engines is a registered trademark of Financial Engines, Inc. All trademarks, logos, service marks, and design elements used are owned by their respective owners and are used by permission Financial Engines, Inc. All rights reserved. Empower Retirement provides plan recordkeeping and administrative services. Future results are not guaranteed by FEA, AAG or any other party. Empower Retirement refers to the products and services offered in the retirement markets by Great-West Life & Annuity Insurance Company (GWL&A), Corporate Headquarters: Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York, Home Office: White Plains, NY; and their subsidiaries and affiliates. The trademarks, logos, service marks, and design elements used are owned by their respective owners and are used by permission.

4 DTE Energy Company Savings and Stock Ownership Plan Rollover Certification 1 Your Personal Information (Please use ink and print in capital letters) Social Security Number Daytime Phone Number Evening Phone Number For GWF use only Last Name First Name MI Address City State Zip Address 2 Rollover Information If you are rolling money from a prior employer's plan, please complete section A ONLY. If you are rolling money from another plan within 60 days after you received a distribution, please complete section B ONLY. If you are rolling money from an IRA, please complete section C ONLY. A Certification of Rollover From Prior Employer Your prior employer's plan administrator must complete and sign this section and return this form to you. Prior Employer Prior Employer's Plan Name Prior Employer's Phone Please check plan type: o 401(a)/401(k) o 457(b) o 403(b) o Rollover IRA Does your rollover contain any after-tax contributions? o no o yes amount $,,. (not including Roth 401(k) contributions) Is this a rollover from a Roth 401(k) account? o no o yes If yes, please attach your prior employer's Roth 401(k) account distribution statement, or complete the following: o This is a Qualified Distribution - or - o This is not a Qualified Distribution. Indicate the following: Year of first Roth 401(k) contribution: Indicate amount of basis: $,,. I certify that, to the best of my knowledge, the rollover distribution being made from the plan identified above is an eligible rollover distribution as defined under the Internal Revenue Code. Plan administrator's Last Name Plan administrator's First Name MI Plan Administrator's Title Plan Administrator's Phone X Plan administrator's signature AE-DTE Continued on the next page

5 Rollover Certification For GWF use only Rollover Information (continued) B Certification of Rollover From Another Plan within 60 Days of Distribution You, the participant, must complete this section. I certify that all funds being rolled over were received in a distribution within the last 60 days from the plan identified below. None of the funds are after-tax amounts. Distributing plan: Name of employer Plan name Please check plan type: o 401(a)/401(k) o 403(b) o 457(b) Is this a rollover of earnings from a Roth 401(k) account? o yes o no If yes, a separate Roth 401(k) rollover account will be established for you. Note: If you received a distribution from a roth 401(k) account, you may not roll over the Roth 401(k) contributions or any portion of a qualified distribution, only the earnings received in a nonqualified distribution. I have documentation that can prove each of these statements and agree to provide this documentation to the plan upon request. I understand that the plan will rely on the truth of these certifications and that if any of these certifications are false, there may be severe financial consequences to me and to the plan. In consideration for the acceptance of my rollover contribution, I agree to be financially responsible for these consequences. X Participant's signature C Certification of Rollover From Your IRA You, the participant, must complete this section. I certify that all funds this plan will receive are from an IRA account and are eligible for rollover to this plan. I specifically certify that (check one or both): o Rollover IRA: The only contribution made to my rollover IRA was an eligible rollover distribution from a retirement plan maintained by my prior employer. o Traditional IRA: The only money being rolled over is from deductible IRA contributions and their earnings. No non-deductible contributions or amounts attributable to Roth IRAs are included. To the best of my knowledge, my IRA is qualified under Section 408 of the tax code. I have documentation that can prove each of these statements and agree to provide this documentation to the plan upon request. I understand that the plan will rely on the truth of these certifications and that if any of these certifications are false, there may be severe financial consequences to me and to the plan. In consideration for the acceptance of my rollover contribution from my rollover IRA or traditional IRA, I agree to be financially responsible for these consequences. X Participant's signature 3 Where to Send Your Form Once you receive this completed form from your prior plan administrator, return it with the check and your completed rollover application to Empower Retirement P.O. Box Kansas City, MO AE DTE