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May be subject to federal income tax and a 10% federal penalty tax. Print in capital letters using blue or black ink. 1 Section 6 Medallion Signature Guarantee : If you recently made a change to your mailing address or to your banking information on file, the Plan will not be able to send your redemption proceeds for 30 days after the receipt of this request UNLESS you provide a Medallion Signature Guarantee. You will also need to provide a Medallion Signature Guarantee for requests of withdraw.

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