IBEW LOCAL NO. 812 ANNUITY PLAN QUALIFIED JOINT AND SURVIVOR ANNUITY NOTICE. Participant s Name: Date of Notice: Date Benefits Are to Commence:

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1 IBEW LOCAL NO. 812 ANNUITY PLAN QUALIFIED JOINT AND SURVIVOR ANNUITY NOTICE Participant s Name: Date of Notice: Date Benefits Are to Commence: Married Participant As a married Participant in the IBEW Local No. 812 Annuity Plan, you have accumulated monies in your Account that will be paid to you under the provisions of the Plan s Plan of Benefits. This Notice will explain to you the qualified joint and survivor Annuity, which is the form in which your Account balance will be paid unless you make the election provided for in this Notice. In order to receive a lump-sum distribution, you must make an election provided for in this Notice. A Qualified Joint and Survivor Annuity form of benefit provides you with a monthly payment for your life, and, upon your death, a monthly payment during your Eligible Spouse s life equal to 50% of the monthly payment you received prior to your death. Eligible Spouse means a Spouse who has been married to you for the one-year period ending on the earlier of: (a) the day on which your benefits commence, or (b) the day you die. If a Spouse was married to you during the one-year period ending on the day your benefits commence, the Spouse need not be married to you at the time of your death in order to be eligible. If a Spouse is married to you for less than one year on the day your benefits commence, but you have been married for at least one year ending on the date of your death, the Spouse is eligible. If a Qualified Domestic Relations Order provides that a former Spouse is not entitled to a survivor benefit, the Spouse shall not be eligible. Because your Eligible Spouse will receive a 50% survivor payment, the relative financial effect of the Qualified Joint and Survivor Annuity is to reduce the monthly payments you would otherwise have received had payments been made to you as a single life annuity. The effect of the Qualified Joint and Survivor Annuity form of benefit is demonstrated by the attached Retirement Option Form - Part I, which contains examples of forms of benefits offered by the Plan. You may elect in writing not to receive your benefits in the form of a Qualified Joint and Survivor Annuity. You must make this election during the 180-day period before your benefits are due to commence. However, your Eligible Spouse must consent in writing before a Plan representative or notary public to your election. You may also revoke this election before your benefits begin. For at least 30 days after you receive this Notice, you have the right to consider your decision whether to consent to a distribution of your Account and whether to elect a direct rollover of any portion of your eligible rollover distribution. If you sign and return the attached Bene-

2 fit Election Form to the Fund s Contract Administrator less than 30 days after you receive this Notice, the Contract Administrator s receipt of your signed form is your affirmative waiver of any unexpired portion of the minimum 30-day period and your affirmative election of a distribution or a direct rollover. In the event you elect to waive the Qualified Joint and Survivor Annuity form of benefit, and your Eligible Spouse has consented to such waiver, your benefits will be distributed in an alternative method described in the attached Retirement Option Form Part 1. It is important that you understand your rights and obligations regarding the Qualified Joint and Survivor Annuity form of benefit and any alternative form of benefit. You should direct any questions to the Contract Administrator, SVS Associates, Inc., 248 Parrish Street, Wilkes-Barre, Pennsylvania ; Telephone: (570)

3 IBEW LOCAL NO. 812 ANNUITY PLAN BENEFIT ELECTION FORM Participant s Name: Date: Account Balance: The Plan s records indicate that you have accumulated the above amount in your Annuity Plan Account as of. Under the terms of the Plan s Plan of Benefits, Accounts are valued daily. Therefore, since your Account is valued daily, the actual Account Balance that will be distributed to you may be higher or lower than the Account Balance shown above, depending on the date of distribution. All of the amounts shown in the Options below are based on the above Account Balance; therefore, the actual amount of the Options will be different at the time of distribution. You have been given a document entitled Special Tax Notice Regarding Plan Payments. You should have read that document carefully before you complete this form. The normal form of benefit for married participants is a 50% joint and survivor annuity ( Qualified Joint and Survivor Annuity ). Please select the option of your choice: I. PAYMENT OPTIONS Option 1: Lump-sum Payment (Total or Partial Payment) Effective Date: This option will provide an immediate lump-sum payment of $. Following the distribution, you and/or your designated beneficiary will have no remaining benefits under the Annuity Plan. (or if partial: Any account balance following this distribution will remain in the Annuity Plan.) Option 2: 50% Qualified Joint and Survivor Annuity Effective Date: If you elect this type of benefit, you will receive a monthly insurance annuity for the rest of your life and, at your death, if your Eligible Spouse is then living, he/she will receive a monthly insurance annuity of 50% of the amount you were receiving per month for the rest of his/her life. Upon the death of the survivor, all benefit payments will cease. Option 3: 75% Joint and Survivor Annuity Effective Date: If you elect this type of benefit, you will receive a monthly insurance annuity for the rest of your life and, at your death, if your Eligible Spouse is then living, he/she will receive a monthly insurance annuity of 75% of the amount you were receiving per month for the rest of his/her life. Upon the death of the survivor, all benefit payments will cease.

4 Option 4: Installment Payment Effective Date: By electing this option, you are electing to receive an installment payment either monthly, quarterly or annually until the balance of your Annuity Account has been depleted. Option 5: Rollover Option Effective Date: By electing this option, the money in your Annuity Account will be rolled over directly to another qualified employer plan or IRA. II. ILLUSTRATION OF PAYMENT OPTIONS The chart below outlines the financial effect of selecting the Lump-Sum Payment, 50% Qualified Joint and Survivor Annuity, 75% Joint and Survivor Annuity and Installment Payment forms of benefit. The amounts used in following example are estimates payable to a hypothetical Participant with a $50,000 account balance at ages 55, 60 and 65. Illustrations Optional Form Lump Sum in Cash 50% Qualified Joint and Survivor Annuity * 75% Joint and Survivor Annuity * Installment Payment Age 55 Commencement Amount of Distribution $50,000 one-time benefit Age 60 Commencement Amount of Distribution $50,000 one-time benefit Age 65 Commencement Amount of Distribution $50,000 one-time benefit $ per month $ per month $ per month $ per month $ per month $ per month To be selected by Participant To be selected by Participant To be selected by Participant * The interest rate that applies to any distribution is assumed to be 3%, and the applicable mortality table is the RP2000 Combined Healthy Mortality Table with Generational Projection Using Scale BB. The calculation of the 50% Qualified Joint and Survivor Annuity and 75% Joint and Survivor Annuity assumes that the Eligible Spouse is two (2) years younger than the Participant. The amount of the 50% Qualified Joint and Survivor Annuity and 75% Joint and Survivor Annuity will depend on the actual age of the Participant and Eligible Spouse at the time payments are commenced. Note: The above amounts are estimates only and are intended to illustrate the approximate amounts payable under the various optional forms of benefit available under the Plan. If you actually elect to receive an annuity form of benefit, the annuity will be provided by purchasing an annuity contract from an insurance company with the money in your account under the Plan. The actual amount of your monthly payments will depend upon the annuity rates being charged by the insurance company at the time the annuity is actually purchased. The annuity rates are based on a number of factors, including your account balance, your age, and your Eligible Spouse's age.

5 If you have any questions regarding information provided in this Notice, you should contact the Plan s Contract Administrator, SVS Associates, Inc. You may also obtain annuity values for the 50% and 75% Joint and Survivor Annuity specific to you based on your Account Balance, your age, and your Eligible Spouse s age by contacting the Contract Administrator. III. ELECTION OF FORM OF PAYMENT I hereby acknowledge that my Eligible Spouse and I have been given the Joint and Survivor Notice. I agree that if the Joint and Survivor Notice was provided to us after 30 days before my benefits are due to commence, my benefits may commence before the 30 days have elapsed but no sooner than 7 days after the Notice was provided to us. I hereby acknowledge that I have been informed by the Contract Administrator that my benefits under the Plan will be paid to me in the form of a Qualified Joint and Survivor Annuity. I have the right to waive the form of payment, provided my Eligible Spouse consents to the waiver. I understand the terms of a Qualified Joint and Survivor Annuity and the financial effect of a waiver, and that I may revoke any waiver in effect. I have had the opportunity to ask any and all questions. I WISH TO SELECT OPTION #. Participant Signature Date If you have selected an option other than the Qualified Joint and Survivor Annuity, your Eligible Spouse should read, complete, and sign, in the presence of a Plan Representative or Notary Public, Section IV: Eligible Spouse s Agreement to Give up Rights to Qualified Joint and Survivor Annuity. This must be done before benefits can begin.

6 IV. ELIGIBLE SPOUSE S AGREEMENT TO GIVE UP RIGHTS TO Spouse s QUALIFIED Agreement JOINT to Give & Up SURVIVOR Rights to Qualified ANNUITY Joint & Survivor Annuity Participant s Name: Date: 1. What is a Qualified Joint & Survivor Annuity (QJSA)? The IBEW Local No. 812 Annuity Plan s Plan of benefits requires the Plan to pay retirement benefits in a special payment form unless your Spouse chooses a different payment form and you agree to that choice. This special payment form is often called a Qualified Joint and Survivor Annuity or a QJSA payment form. The QJSA payment form gives you a monthly retirement payment for the rest of your life. Under the QJSA payment form, after your Spouse dies, each month the Plan will pay you fifty (50%) percent of the retirement benefit that was paid to your Spouse. The benefit paid to you after your Spouse dies is often called a survivor annuity or a survivor benefit. You will receive this survivor benefit for the rest of your life. 2. Who is an Eligible Spouse under the Plan? Under the Plan, in order to be eligible, a Spouse must have been married to the participant for the one-year period ending on the earlier of (a) the day on which benefits commence, or (b) the day the participant dies. If a Spouse was married to the participant during the one-year period ending on the day benefits commence, the Spouse need not be married to the participant at the time of his death in order to be eligible. If a Spouse is married to a participant for less than one year on the day benefits commence, but has been married for at least one year ending on the date the participant dies, the Spouse is eligible. If a Qualified Domestic Relations Order provides that a former Spouse is not entitled to a survivor benefit, the Spouse shall not be eligible. If a Qualified Domestic Relations Order provides that a former Spouse is entitled to a survivor benefit, the provisions stated above will not be applicable unless they are consistent with such Order. 3. How Can Your Spouse Change the Way Benefits Are Paid? Your Spouse and you will receive benefits from the Plan in the special QJSA payment form required by the Plan s Plan of Benefits unless your Spouse chooses a different payment form and you agree to the choice. If you agree to change the way the Plan s retirement benefits are paid, you give up your right to the special QJSA payments.

7 4. Do you have to Give Up Your Right to the QJSA Benefit? Your choice must be voluntary. It is your personal decision whether you want to give up your right to the special QJSA payment form. 5. What Other Benefit Forms can my Spouse Choose? If you agree, your Spouse can choose to have the retirement benefits paid in a different form. Other payment forms may give your Spouse larger retirement benefits while he or she is alive, but might not pay you any benefits after your Spouse dies. 6. Can Your Spouse Make Future Changes if you Sign the Agreement? If you sign this Agreement, you agree that benefits under the Plan will be paid in the form stated in this Agreement. 7. Can You Change Your Mind After You Sign this Agreement? You cannot change this Agreement after you sign it. Your decision is final. 8. What Happens to this Agreement if You Become Separated or Divorced? Legal separation or divorce may end your right to survivor benefits from the Plan, even if you do not sign this Agreement. However, if you become legally separated or divorced, you might be able to get a special court order (which is called a qualified domestic relations order ) that would give you the right to receive retirement benefits even if you sign this Agreement. If you are thinking about separating or getting a divorce, you should get legal advice on your rights to benefits from the Plan. 9. What Should You Know Before Signing this Agreement? This is a very important decision. You should think very carefully about whether you want to sign this Agreement. Before signing, be sure that you understand what retirement benefits you may get and what benefits you will no longer be able to receive. Your Spouse should have received information on the types of retirement benefits are available from the Plan. If you have not seen this information, you get it and read it before you sign this Agreement. For additional information, you can contact SVS Associates, Inc., 248 Parrish Street, Wilkes-Barre, Pennsylvania ; Telephone: (570)

8 10. Eligible Spouse s Agreement I,, am the Eligible Spouse of. I understand that I have the right to have IBEW Local No. 812 Annuity Plan pay my Spouse s retirement benefits in a QJSA payment form and I agree to give up that right. I understand that by signing this Agreement I may receive less money than I would have received under the QJSA payment form, and I may receive nothing after my Spouse dies, depending on the payment form or beneficiary that my Spouse chooses. I agree that my Spouse can receive retirement benefits in the form of a I understand that my Spouse cannot choose a different form of retirement benefits or a different beneficiary unless I agree to the change. I understand that I do not have to sign this Agreement, I am signing this Agreement voluntary. I understand that if I do not sign this Agreement, then my Spouse and I will receive payments from the Plan in the QJSA payment form. I hereby acknowledge that my Spouse and I have been given the Joint and Survivor Notice. I agree that if the Joint and Survivor Notice was provided to us after 30 days before his/her benefits are due to commence, his/her benefits may commence before the 30 days have elapsed but no sooner than 7 days after the Notice was provided to us. Signed this day of 20. Eligible Spouse Signature Participant Signature Eligible Spouse Social Security Number Participant Social Security Number Witnessed: Annuity Plan Representative or Notary Public

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