Fidelity Investments 1. PARTICIPANT INFORMATION 2. HOUSING ALLOWANCE DESIGNATION FOR MINISTERS 3. REASON FOR DISTRIBUTION

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1 Fidelity Investments Distribution Form Church of the Nazarene 403(b) Retirement Savings Plan Plan #72185 Instructions: Use this form if you wish to request a distribution from your Church of the Nazarene 403(b) Retirement Savings Plan account. Please complete this form and unless otherwise directed return it to: Pensions and Benefits USA Church of the Nazarene Prairie Star Parkway Lenexa KS Questions? Call Fidelity Investments at NAZARENE ( ) Monday through Friday from 7 a.m. to 11 p.m. Central time. Please use a pen and print clearly in CAPITAL LETTERS. A. Your Information Social Security #: 1. PARTICIPANT INFORMATION First Name: M.I. Last Name: Date of Birth: Street Address: City: State: Zip: Daytime Phone: Evening Phone: Ordained or District-Licensed Nazarene Minister Other Employee 2. HOUSING ALLOWANCE DESIGNATION FOR MINISTERS I certify that I am eligible for a Nazarene Minister s Housing Allowance* *Note: Minister s Housing Allowance partial withdrawals will be coded as taxable amounts not determined on IRS Form 1099-R. It is the minister s responsibility to meet the IRS guidelines on the amount of Housing Allowance that can be nontaxable. 3. REASON FOR DISTRIBUTION Attainment of age 59½ Attainment of age 62 Separation from service* Financial hardship Disability * See below. Please be sure to indicate which permitted Financial Hardship expense applies to your situation. In addition please be aware that if you receive a withdrawal before you reach age 59½ there may be a 10% early withdrawal penalty assessed by the IRS. Please see Section 5 of this form for more information on noneligible rollover amounts. By electing to receive a financial hardship distribution you hereby certify that you have incurred a financial hardship due to the reason stated below and that the withdrawal amount designated on this form is necessary to meet your financial need created by the hardship to the extent that no other funds are reasonably available. Furthermore you certify you have determined that the amount of your financial hardship cannot be satisfied by any other distributions and nontaxable loans currently available under all plans maintained by the Church of the Nazarene. Please note that you are responsible for retaining the original documentation necessary to verify that a financial hardship did exist at the time you made the request for such financial hardship. Please call NAZARENE ( ) for more information concerning financial hardship withdrawals. Financial Hardship Please indicate which permitted expense applies: Purchase of a principal residence College expenses for the next 12 months Uninsured medical expenses for me my spouse or my dependents To prevent eviction from or foreclosure of my principal residence Burial expenses Damage to principal residence

2 4. METHOD OF DISTRIBUTION PAYMENT On the following pages you will be given your choice of five distribution methods that may be available: Full Withdrawal Partial Withdrawal Systematic Withdrawal Plan (SWP) Direct Rollover An Income Annuity (Annuity IRA) If you are taking a distribution for financial hardship reasons please note that you cannot choose Systematic Withdrawal Plan Direct Rollover or an Income Annuity. You may choose a combination of the above methods or just one at this time. If you would like more information about these methods including general tax implications please call NAZARENE ( ) Monday through Friday from 7 a.m. to 11 p.m. Central time. Method 1: Full Withdrawal By check Deposit into a Fidelity nonretirement account Account #: INDICATE HOW YOU WOULD LIKE THE PAYMENT (If a new account please attach an account application to this form.) Note: Minister s Housing Allowance full withdrawals will be coded as taxable amounts not determined on IRS Form 1099-R. It is the minister s responsibility to meet the IRS guidelines on the amount of Housing Allowance that can be nontaxable. Method 2: Partial Withdrawal INDICATE AMOUNT TO BE WITHDRAWN AND WHERE PAYMENT SHOULD COME FROM Withdraw proportionally across all available sources/investment options $ Withdraw from specific sources/investment options: OR 1. Investment Option: Employer Source(s) both APS and Non-APS Money Employee Source(s) 2. Investment Option: $ or 100% Employer Source(s) both APS and Non-APS Money Employee Source(s) $ or 100% INDICATE HOW YOU WOULD LIKE THE PAYMENT By check Deposit into a Fidelity nonretirement account Account #: (If a new account please attach an account application to this form.) Note: Minister s Housing Allowance partial withdrawals will be coded as taxable amounts not determined on IRS Form 1099-R. It is the minister s responsibility to meet the IRS guidelines on the amount of Housing Allowance that can be nontaxable. Electronic Funds Transfer (EFT requires a 15-day setup period prior to processing a distribution). Complete the enclosed EFT application and attach a voided check. If your plan is not set up for distributions via EFT you will receive your distribution by check.

3 4. METHOD OF DISTRIBUTION PAYMENT (CONTINUED) Method 3: Systematic Withdrawal Plan (SWP) SWPs are distributions in the form of periodic payments; please fill in the amount you wish to receive. The monies will be taken proportionally across all available sources/investment options. This method of distribution is not available for reasons of Financial Hardship. CHOOSE ONE SWP METHOD BELOW Specific Dollar Method: If you would like a specific amount sent to you on an installment basis check the Specific Dollar Method and list the amount you would like to receive each time. Also indicate the date you would like to begin receiving distributions and at what intervals (monthly quarterly or annually). Twenty percent deferral income tax will be withheld on specific dollar systematic withdrawal plans. This method will continue until the full balance of your account has been distributed. You may change or discontinue this option at any time in writing or via phone. Please allow five business days to process any change. Pay me $ beginning: each period. To be paid: Monthly Quarterly Annually Distribute from: Proportionally across all available sources and investment options Specific Period Method: If you would like to pay out your entire account balance over a period of time check the Specific Period method. However if the period is less than 10 years then 20% federal income tax will be withheld for each distribution. You may change or discontinue this option at any time in writing or via phone. Please allow five business days to process any change. To be paid: By check Monthly Quarterly Annually for years beginning: INDICATE HOW YOU WOULD LIKE THE PAYMENTS Electronic Funds Transfer (Complete the enclosed EFT application and attach a voided check.) Deposit into a Fidelity nonretirement account Account #: (If a new account please attach an account application to this form.) Note: Minister s Housing Allowance systematic withdrawals will be coded as taxable amounts not determined on IRS Form 1099-R. It is the minister s responsibility to meet the IRS guidelines on the amount of Housing Allowance that can be nontaxable

4 4. METHOD OF DISTRIBUTION PAYMENT (CONTINUED) Method 4: Direct Rollover This method of distribution is not available for reasons of Financial Hardship. Direct Rollover to an IRA or a Roth IRA with Fidelity Is the new account: an IRA? a Roth IRA? CHOOSE ONE ROLLOVER BELOW Note: Distributions paid under an IRA are not eligible for a Minister s Housing Allowance under current tax law. I would like my rollover to be directed to the same Fidelity mutual fund(s) and in the same proportion as I currently have in my Employer s plan. I understand that you will transfer any money invested in nonmutual funds such as non-fidelity Investments annuities and any non-fidelity mutual funds to Fidelity Cash Reserves a money market fund. I acknowledge that I have read the Fidelity Cash Reserves prospectus. Account #: Note: If you do not have a Fidelity Rollover IRA you must also complete a Fidelity Investments rollover IRA Application. Direct Rollover to another custodian/trustee Is the new account: an IRA? a Roth IRA? a 403(b) plan? Other? Provide us with the name of the receiving custodian/trustee. A check will be made payable to the receiving custodian/trustee on your behalf and will be mailed directly to you. Forward the check to the receiving custodian/trustee. Direct Rollover to an existing retirement plan at Fidelity. (Example: new employer s plan) Name of receiving plan: INDICATE AMOUNT OF ROLLOVER AND WHERE ROLLOVER SHOULD COME FROM Roll over my entire eligible account balance. OR Roll over $ OR proportionally across all available sources/investment options. Roll over specific sources/investment options: 1. Investment Option: Employer Source(s) both APS and Non-APS Money Employee Source(s) $ 2. Investment Option: OR 100% Employer Source(s) both APS and Non-APS Money Employee Source(s) $ OR 100%

5 4. METHOD OF DISTRIBUTION PAYMENT (CONTINUED) Method 5: Income Annuity (Annuity IRA) This option lets you select an income annuity which provides you (or you and your spouse) a guaranteed income for life or a specific length of time. This method of distribution is not available for reasons of Financial Hardship. CHOOSE ONE ANNUITY OPTION BELOW Fidelity Income Annuity I would like to roll over money from my account to purchase Fidelity s Income Advantage Annuity. Note: Please call NAZARENE ( ) Monday Friday from 7 a.m. to 11 p.m. Central time to request an application and additional information. Fidelity s Income Annuity is issued by Fidelity Investments Life Insurance Company and for New York residents Empire Fidelity Investments Life Insurance Company New York N.Y. A non-fidelity Income Annuity Name of Annuity Provider: I would like to purchase a: 50% Qualified joint and survivor annuity % qualified joint and survivor annuity Fidelity will transfer the proceeds of your account to the insurance company you select once we receive a completed annuity contract application signed by you and a letter of acceptance signed by the insurance company. Note: Distributions paid under an income annuity are not eligible for a Minister s Housing Allowance under current tax law. INDICATE AMOUNT OF THE ANNUITY AND FROM WHERE THE ANNUITY WILL BE PURCHASED Purchase an annuity proportionally across all available investment options for: $ Purchase an annuity from specific sources/investment options OR 1. Investment Option: Employer Source(s) both APS and Non-APS Money Employee Source(s) $ or 100% 2. Investment Option: Employer Source(s) both APS and Non-APS Money Employee Source(s) $ or 100%

6 5. INCOME TAX WITHHOLDING Eligible Rollover amounts and Noneligible Rollover amounts are subject to an income tax withholding. If you have certified your eligibility to receive this distribution as a Nazarene Minister s Housing Allowance under Distribution Method 1 2 or 3 this Section 5 does not apply. Eligible Rollover Amounts: Eligible rollover amounts that are not rolled directly to an IRA or another eligible retirement plan are subject to mandatory withholding of 20% for federal income taxes. A payee cannot elect out of this withholding. Many states require that state income taxes be withheld whenever federal income taxes are withheld. Noneligible Rollover Amounts: The following payments are not considered eligible rollover amounts: a minimum required distribution; level payments over at least ten years or if less the payee s life expectancy; death benefit payments to nonspouse; or financial hardship withdrawals. Taxable amounts that are not eligible for rollover are subject to federal income tax withholding unless the payee elects out of withholding. If the payment(s) occurs in one tax year (a nonperiodic payment) the default federal income tax withholding is 10%. When the payments are made over two or more tax years (level periodic payments) the default federal income tax withholding is based on the withholding tables using married (filing joint return) with three withholding allowances. If this payment is a noneligible rollover amount a payee can elect out of this default withholding by selecting the following: Minister Housing Allowance: Unless otherwise directed by you we will automatically withhold 10% for federal income taxes. You may choose to elect out of federal income tax withholding at the time of your hardship distribution. Please mark the box I elect not to have federal income taxes withheld from my distribution. Minister Housing Allowance withdrawals are coded as taxable amounts not determined on IRS Form 1099-R. It is the minister s responsibility to meet the IRS guidelines on the amount of Housing Allowance that can be nontaxable. I elect not to have federal income taxes withheld from my distribution. Eligible rollover amounts not directly rolled over are subject to mandatory withholding of 20% for federal income taxes. A payee cannot elect out of this withholding. I elect not to have state income taxes withheld from my distribution. Please note that some states require state income tax to be withheld. I have enclosed an IRS Form W-4P to request that federal and state income tax withholding be based on the elections/ directions in this form. Please note that some states may not base income tax withholding on the Form W-4P. If you are a nonresident alien you must submit IRS Form W-8BEN Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding with this Distribution Request Form to claim tax treaty benefits if applicable. Please note that a payment to an address outside of the United States will be withheld at a 30% rate unless the payee submits a completed IRS Form W-8BEN. Please go to the IRS Web site to download the form or visit an IRS office. 6. SPOUSAL CONSENT Single Married I hereby consent to the election of distribution as indicated by my spouse to have Church of the Nazarene 403(b) Retirement Savings Plan benefits paid in the form specified. Signature of Participant s Spouse: X Date:

7 7. YOUR SIGNATURE I certify that all information provided by me on this form is true and accurate. I hereby certify under penalties of perjury that my Social Security number in Section 1 of this form is correct and that I have read the Special Tax Notice Regarding Plan Payments. Signed: X Date: Please return your completed and signed form to: Pensions and Benefits USA Church of the Nazarene Prairie Star Parkway Lenexa KS EMPLOYER AND BENEFIT USE ONLY Hardship Distribution Certification by Participating Employer: This certifies on behalf of Employer Name that the circumstances noted in Section 3 of this form are accurately represented by the employee named in Section 1 of this form and therefore constitute an appropriate basis for this distribution being requested. Signed: X Date: Print Name: Title: Distribution: The distribution requested on this form is subject to the approval of Pensions and Benefits USA. Approval is required before any distribution can be made. On behalf of (name of participant): I approve the distribution described on this form. Signed: X Date: Print Name: Title:

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