TRUSTED SYSTEMS, INC. 401(K) PS PLAN & TRUST Rollover Contribution

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1 This form may be used to move retirement plan assets from a retirement plan or traditional or SIMPLE IRA into your employer s plan. This form may NOT be used to request a rollover from this plan to another retirement plan. Initiating Your Rollover Contact your prior Employer/Investment Company to request a distribution of your account balance. Please have check made payable to: Frontier Trust FBO Participant Name and Social Security Number Information 1. Overall Amount The amount of my rollover contribution is $. 2. Roth Elective Deferrals The amount of my rollover contribution attributable to Roth elective deferrals is $. (If you enter zero, skip items 3 and 4 and proceed to item 5.) 3. Roth Earnings The amount of my rollover contributions attributable to earnings on Roth elective deferrals is $. 4. Initial Roth Contribution The first year in which I made a Roth elective deferral to the plan from which my rollover is being made was. 5. After Tax Contributions The amount of my direct rollover contribution attributable to any non Roth after tax amounts is $. 6. Origin of The rollover contribution is from the following type of Plan: Qualified Plan 403(a) Plan 403(b) Plan 457(b) Plan Traditional IRA SIMPLE IRA Roth 401(k) Roth 403(b) Rollover Investment Elections Identify the fund(s) in which you would like your rollover contribution invested by selecting one of the boxes below. Missing or incomplete information may cause a delay in the processing of your transaction. Invest according to my current investment elections. (Check this box to invest your rollover contribution in the same funds and percentages that apply to your other contributions.) Invest my rollover contribution as described below. You have a choice of how to invest your retirement accounts. You may divide your investments in 1% multiples among the funds. Alternatively, you may choose the Model Portfolio option. Please note that, if you choose to invest in a model, you must invest 100% of your contributions in that option. IMPORTANT NOTE: if you choose to invest in a model portfolio, 100% of your account balance must be invested in that model portfolio. This includes rollover contributions. Therefore, if you are already enrolled in the plan and currently invested in a model portfolio, 100% of your rollover will also be invested in that model portfolio, even if you choose different funds on this form. If you choose to invest in a model portfolio any time in the future, 100% of your account balance including your rollover will be invested in that model portfolio. Please indicate the percentage you would like to contribute to the following funds. You may divide your investments in 1% multiples and your total must equal 100%. If you would like more information on specific funds, please review the fund sheets provided. Option 1: Select Funds ABernstein Small/Mid Cap Value Fund (A) American Funds EuroPacific Growth Fund (R6) American Funds Fundamental Investors (R6) BlackRock Equity Dividend Fund (A) 63

2 Columbia Acorn Fund (Z) DFA Emerging Markets Core Equity Fund (I) DFA International Small Company Fund (I) DFA International Value Fund (I) DFA Large Cap International Fund (I) DFA U.S. Core Equity 1 Fund (I) DFA U.S. Large Cap Value Fund (I) DFA U.S. Small Cap Fund (I) DFA U.S. Targeted Value Fund (I) DFA U.S. Vector Equity Fund (I) Dodge & Cox International Stock Fund Principal MidCap Blend Fund (I) T. Rowe Price Blue Chip Growth Fund T. Rowe Price New Horizons Fund Vanguard 500 Index Fund (Inv) Vanguard Growth Index Fund (Inv) Vanguard Mid Cap Growth Index Fund (Inv) Vanguard Mid Cap Index Fund (Inv) Vanguard Small Cap Growth Index Fund (Inv) Vanguard Small Cap Index Fund (Inv) American Funds Capital World Bond Fund (R6) PIMCO Total Return Fund (D) Vanguard Target Retirement 2010 Fund (Inv) Vanguard Target Retirement 2015 Fund (Inv) Vanguard Target Retirement 2020 Fund (Inv) Vanguard Target Retirement 2025 Fund (Inv) Vanguard Target Retirement 2030 Fund (Inv) Vanguard Target Retirement 2035 Fund (Inv) Vanguard Target Retirement 2040 Fund (Inv) Vanguard Target Retirement 2045 Fund (Inv) Vanguard Target Retirement 2050 Fund (Inv) Vanguard Target Retirement Income Fund (Inv) MetLife GAC Class III 64

3 Option 2: Choose Model Portfolio (Select only one below.) MODERATE MODEL BALANCED MODEL GROWTH AND INCOME MODEL MODERATELY AGGRESSIVE MODEL AGGRESSIVE GROWTH MODEL If you do not choose investments for your savings, your contributions will be invested in the applicable investment option listed below, determined by your date of birth and number of years until retirement (the years listed below are based on your year of birth). Investment Option Name Start Year End Year Vanguard Target Retirement Income Fund (Inv) 01/01/ /31/1942 Vanguard Target Retirement 2010 Fund (Inv) 01/01/ /31/1947 Vanguard Target Retirement 2015 Fund (Inv) 01/01/ /31/1952 Vanguard Target Retirement 2020 Fund (Inv) 01/01/ /31/1957 Vanguard Target Retirement 2025 Fund (Inv) 01/01/ /31/1962 Vanguard Target Retirement 2030 Fund (Inv) 01/01/ /31/1967 Vanguard Target Retirement 2035 Fund (Inv) 01/01/ /31/1972 Vanguard Target Retirement 2040 Fund (Inv) 01/01/ /31/1977 Vanguard Target Retirement 2045 Fund (Inv) 01/01/ /31/1982 Vanguard Target Retirement 2050 Fund (Inv) 01/01/ /31/9999 If you do not choose your investments for your savings and you do not have a date of birth on file, your contributions will be invested in an investment as determined by your Plan Administrator. Participant Authorization My signature confirms that I have read, understand and agree with the information contained on the reverse side of this form. I certify that amounts represented on this form qualify as a rollover contribution. Furthermore, I hereby direct that the investment elections specified on this form be made in my Plan account for this rollover contribution. Signature of Participant: Date: Plan Administrator Use Only Mail the completed Form and the original rollover check made payable to Frontier Trust to: Frontier Trust PO Box Fargo, ND Overnight Address Frontier Trust 1126 Westrac Drive Fargo, ND Note: 1. Your check must be payable to Frontier Trust. 2. Please include your social security number on your check. 3. If more than one rollover contribution is being sent, please use a separate Form for 65

4 each request. If you have questions while completing this form, please contact the Plan Information Line at Date check mailed to the Trust: (MM/DD/YYYY) Please check here if this is a related rollover. I authorize the receipt of the rollover into the Employer Plan designated above. Signature of Plan Administrator: Date: NOTE: To process this request in the most efficient manner, please utilize your plan sponsor web site. 66

5 Making a to the Plan By completing this form and preparing (or endorsing) your rollover check to Frontier Trust you can affect a rollover contribution to this Plan. A rollover contribution is a tax free transfer of retirement plan assets from one retirement plan or a traditional or SIMPLE IRA into another plan. Your Plan Administrator may ask you for additional information in order to verify that the funds you are contributing qualify as a rollover contribution. Once completed, you should forward the form to your Plan Administrator for approval. Note: If this rollover contribution is being made during or after the first year for which you must take a Required Minimum Distribution, you cannot roll over any distribution which would constitute a Required Minimum Distribution. Please check with your Plan Administrator for more information about Required Minimum Distributions. How to Complete the Form Please enter your social security number and full name. Information Please indicate the exact dollar amount of your rollover contribution. You should ensure that the amount entered matches your rollover contribution check exactly. You should not complete this form until you are in possession of your rollover check. If applicable, provide details about the Roth portion of your rollover as well as the amount of the rollover contribution attributable to after tax amounts. Also, identify the type of retirement plan the rollover contribution is from. Rollover Investment Elections Please indicate into which investment fund(s) your rollover contribution should be allocated. First locate the name(s) of the investment fund(s) in which you want your rollover contribution invested. Next, in the percent column enter the percent (whole numbers only) of your contribution you want invested in that fund. You can invest in one fund or any combination of funds offered by your Plan. If you do not want any of your contribution invested in a particular fund, leave the corresponding percent column blank. Please be sure that your percentages total 100%. Your instructions will be used to process this rollover contribution only. Note: If no investment elections are made, the amount will be invested in the Default Fund designated by your Plan. Participant Authorization By signing and dating the form, you acknowledge that you have provided your Plan Administrator with accurate information and authorize your Plan's Administrator to act on your request. Plan Administrator Use Only Please verify that: 1. Your plan document permits you to accept rollover contributions. 2. The rollover contribution you are accepting qualifies for rollover treatment. 3. The information completed by your participant is accurate and complete. 67

6 Please complete the following: 1. Enter the date that you are mailing the check to the Trustee. 2. Check the related rollover box if this rollover contribution represents a distribution from another qualified plan sponsored by your company. Please sign and date the form to acknowledge that you, acting as a named and authorized representative of the Plan, confirm that the information provided is complete and accurate and the request is in accordance with this Plan. You authorize this request be processed as instructed. 68