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Formation Participant Name: SSN: DOB: Beneficiary Name: SSN: DOB: Address: City: St: Zip: Home Phone: Work Phone: Plan: Section 2 Election a $30 Withdrawal fee will be assessed for all Rollovers and Cash Distributions After reading the Special Tax Notice that is available on keatinginc.com Regarding Plan Payments, I, the undersigned Participant, make the following distribution election: Choose (A), (B), or (C) (A) 1) A Direct Rollover of my total PRE-TAX Vested Account Balanc.

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