Pentegra Retirement Services

REQUEST FOR WITHDRAWAL FROM A DEFERRED ACCOUNT

IMPORTANT NOTICE:

Please carefully review the Special Tax Notice Regarding Plan Payments, which you previously received,prior to completing this form. If you cannot locate this document, contact your Employer, log on to the Pentegrawebsite, or contact Pentegraand a copy will be sent to you.

PARTICIPANT DATA(Please Type or Print clearly): (Only to be completed by participants who have separated from service)

Name:

Last First Middle Initial

Current Address:

Street City State Zip

Social Security Number: ______E-Mail: ______Home Phone Number

Former Employer Name: Plan ID:

 This withdrawal request is due to disability

TOTAL WITHDRAWAL REQUEST

Total Available Vested Balance

PARTIAL WITHDRAWAL REQUEST

A.Non-401(k) MoniesB.Taxable Monies

 Total of my own pre-1987 after-tax contributions $ ______

Total of my own after-tax contributions + earnings

$______

FORM OF PAYMENT

I irrevocably elect to have:

A. Any amounts distributed from the employer stock fund will be paid In-Kind. Please note that the $150 administration fee for an in-kind distribution of employer securities from the Employer Securities Fund will be paid by First Federal Savings Bank of Champaign-Urbana in the event that the participant requests a distribution of the entire balance invested in the Employer Securities Fund. For partial distributions from the Employer Securities Fund, the participant will be required to pay the $150 fee before the distribution will be made.

DTC instructions:

Institution Name:

Contact Person:

DTC #:

Account #:

Contact Phone #:

B. I irrevocably elect to have (check one):

all of my withdrawal directly rolled over to the IRA, Roth IRA or plan listed below.

$ or % of the taxable portion of my withdrawal directly rolled over to the IRA, Roth IRA or plan listed below and the remaining portion of my withdrawal paid directly to me.

the total amount of my withdrawal (including any taxable portion eligible for rollover) paid directly to me.

Other ______

Some or all of your distribution may be subject to Federal and state income tax withholding. If required by law, Federal income tax will be withheld at a flat rate of 20%. If required by your state, state income tax will be withheld at the prevailing rate for your state. Income taxes that have been withheld cannot be refunded by the Plan for any reason.

I further understand that this withdrawal will be deducted proportionately from the value of my account in each of the available investment funds.

(continued on reverse)

PSI Form G06 508S150 Deferred Withdrawal

DIRECT ROLLOVER INSTRUCTIONS

I hereby instruct the Plan to directly roll over the portion of my taxable distribution indicated above to (please attach a statement from the plan, IRA or Roth IRA certifying its eligibility and willingness to accept this rollover):

Type of Plan (check one):  IRA

 Roth IRA

Qualified retirement plan (e.g., 401(k), profit sharing, 403(a), etc.)

Eligible Section 457(b) plan

Annuity Contract under Section 403(b) of the Internal Revenue Code

Name of Receiving Plan, IRA or Roth IRA:

Address of Receiving Plan, IRA or Roth IRA:

Please send my payment via:

A check sent regular mail.

A check sent overnight mail: a personal check for $25.00, payable to Pentegra Services, Inc., must accompany this request form.

A wire transfer: a personal check for $20.00, payable to Pentegra Services, Inc., must accompany this request form. (complete bank information below)

ACH (Automated Clearing House electronic transfer) - No additional charge.(complete bank information below)

ABA# ______Account # ______

Branch # ______

Name of receiving institution ______

Address of receiving institution ______

Account Name: ______

I hereby certify that I have reviewed the “Special Tax Notice Regarding Plan Payments” within the period required by federal tax law and that I hereby waive the 30 day waiting period as allowed by law. I further certify that the plan or account that I have selected above (if any) is eligible and willing to receive my rollover distributions. I acknowledge a $10 distribution fee will be deducted from the proceeds of my withdrawal.

.

I also certify as outlined in the “Special Tax Notice Regarding Plan Payments” and in the Plan’s Summary Plan Description that my spouse may be required to consent to this withdrawal. If so, a fully completed and executed PSI Form 514, Spousal Consent for a Withdrawal, will be submitted.

Signature of ParticipantDate

State of: ss.:

County of:

On this day of , personally appeared before me the said named

, to me known and known to me to be the person described in and who executed the foregoing instrument, and he(she) acknowledged that he(she) executed the same.

(Seal) (Notary Public)

STAMP OR SEAL REQUIREDMy commission expires Date

PSI FormG06508S150Deferred Withdrawal

Pentegra Retirement Services ·108 Corporate Park Drive·White PlainsNY10604· · Phone 1-866-633-4015· Fax 914-694-6429