Statement Date: Month Day, Year Savings Plus savingsplusnow.com

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1 : Statement Date: Month Day, Year Savings Plus savingsplusnow.com Savings Plus Service Center :00 a.m. to 7:00 p.m., PT, Monday through Friday Employment Status : ACTIVE Rollover-In Form - Savings Plus 401(k) I. INSTRUCTIONS This form must be completely and accurately filled out in order to have your rollover deposited into the Savings Plus 401(k) Plan. Please read this form carefully and follow the instructions provided. II. ROLLOVER CONTRIBUTION Rollover Amount Amount of before-tax rollover $ Amount of designated Roth Rollover $ Roth 401(k) Begin Date If you re rolling over Roth 401(k) balances, enter the date your first Roth contribution was posted to the prior employer plan: Roth begin date *DC0008T *

2 Page 2 You must provide proof to validate the beginning date of your Roth contribution. Note: Roth IRA s are not eligible to roll into the plan. Investing Your Rollover Amount By completing this form, you authorize Savings Plus to deposit the funds from your former Plan or Traditional IRA according to your investment choices on file. If you don't have any investment choices on file, Savings Plus will deposit your rollover contribution in an appropriate Target Date fund based on your date of birth (see defaults by date of birth below). You can transfer the balance to other investment options at any time by logging into your account or calling the Service Center. Birth years 1950 and before = TD Income Birth years = TD 2015 Birth years = TD 2020 Birth years = TD 2025 Birth years = TD 2030 Birth years = TD 2035 Birth years = TD 2040 Birth years = TD 2045 Birth years = TD 2050 Birth years = TD 2055 Birth years = TD 2060 Rollover Check Make check payable to the Plan as follows: Savings Plus 401(k) Plan for the benefit of FIRST NAME LAST NAME ; or Savings Plus 401(k) Plan FBO FIRST NAME LAST NAME. Personal checks will not be accepted and will be returned to you. Rollover ACH Provide the following information to your prior qualified plan or IRA provider to to transfer your funds via ACH ABA Acct Name PTFS Operations FFC P35663/Your social security number Acceptance of Funds: Savings Plus hereby agrees to accept funds associated with this rollover, which came from a qualified plan, a conduit Traditional IRA, or an eligible plan, from the current Trustee/Custodian/Carrier in accordance with the applicable provisions of the Internal Revenue Code.

3 Page 3 Signature III. CERTIFICATION I certify that the amount of my rollover contribution represents only money that is eligible to be rolled over into the Savings Plus 401(k) Plan. If any of the money is subsequently determined to be ineligible for rollover, I understand that the Plan will distribute the ineligible amount and any attributable earnings, if applicable. IV. NEXT STEPS Date Keep a copy of this form for your records. Then fax or mail all pages of this completed, original form (not a copy) and rollover amount, to: Mail: Savings Plus Service Center P.O. Box Charlotte, NC Fax: When faxing your information, do not include a cover sheet. Only fax this form. Your rollover check must be mailed to the address above. Don t fax a copy of the check. Before returning this form, please check to make sure to: Sign and date the form under Section III. If sending a check, enclose the check from the distributing plan or IRA, money order, certified check, or cashier's check for the rollover amount. Make a copy of this form for your personal records. Note: If your rollover contribution can't be processed, you'll receive a notice explaining why and how you can process your rollover request. Detailed eligibility can be found on the following pages.

4 Page 4 Savings Plus 401(k) Plan Rollover Guidelines A. GENERAL INFORMATION In order to make a rollover contribution, you must: Be eligible to participate in the Savings Plus 401(k) Plan or, if you are separated from employment with the State of California, you must have an existing balance in your Savings Plus account. Complete and return this form to the Savings Plus Service Center, verifying the amount is eligible to be rolled over; and Enclose a check from the distributing plan or individual retirement account (IRA), money order, certified check, or cashier's check for the rollover amount or provide ACH information to the distributing provider/plan. Please note that the Savings Plus 401(k) Plan does not accept share certificates as part of a rollover contribution. If you haven't already designated a beneficiary in the Savings Plus 401(k) Plan, you must access the Savings Plus Web site or call the Savings Plus Service Center to make your beneficiary designation. B. WHAT CAN BE ROLLED OVER Rollover Type Your rollover contribution to the Plan may be done by direct rollover or 60-day rollover. Direct Rollover A direct rollover occurs when the distributing eligible employer plan or individual retirement account (IRA) makes the rollover payable directly to the Plan for the benefit of you (FBO). 60-Day Rollover A 60-day rollover occurs when the eligible amount is paid to you and you have 60 days from the date the distribution was made to deposit any of the eligible amount with the Savings Plus 401(k) Plan. If you're doing a 60-day rollover, you must roll over the entire eligible amount, you'll have to find other money to replace the 20% withholding that was taken when the distribution was paid to you. Nontaxable amounts aren't eligible to be rolled over through a 60-day rollover. Eligible Amounts The following amounts are eligible for rollover into the Plan: Taxable amounts from an eligible employer plan Nontaxable amounts from an eligible employer plan, direct rollover only Taxable Roth amounts from an eligible employer plan Nontaxable Roth amounts from an eligible employer plan, direct rollover only Roth amounts from an eligible employer plan, direct rollover only

5 Page 5 C. WHAT CAN'T BE ROLLED OVER Ineligible Amounts The following amounts aren't eligible for rollover into the Plan: Taxable amounts from a conduit IRA Money from a Roth IRA Nondeductible contributions you made to an IRA Amounts paid to you as part of a series of equal or almost equal payments that are made at least once a year and that will last for a) your lifetime (or your life expectancy); b) your lifetime and your beneficiary's lifetime (or your joint life expectancies); or c) a specified or expected period of ten or more years Required minimum distribution payments Hardship distributions Payments made to you as a nonspouse beneficiary or a nonspouse alternate payee Pass through dividend payments Unforeseeable Emergency Distributions D. HOW TO ROLL OVER ELIGIBLE AMOUNTS INTO THE PLAN Required Documentation You must provide your signature in Section III above certifying that the rollover contribution contains only an amount that is eligible for rollover into the Plan and that the amount is coming from an eligible employer plan or IRA.You must provide proof to validate the beginning date of your Roth contributions. For More Information Review your employment status at the beginning of this notice for accuracy. Contact the Savings Plus Service Center toll free at with any discrepancies. Web: Savings Plus at savingsplusnow.com Phone: toll-free at ( SPN), 7:00 a.m. to 7:00 p.m., PT, Monday through Friday. Mail: Savings Plus Service Center Mail: P.O. Box Mail: Charlotte, NC Hablamos español: Para información de beneficios, llama al