PARTICIPANT HARDSHIP STATEMENT. of$ due to hardship for the following reason(s):

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1 PARTICIPANT HARSHIP STATEMENT IMPORTANT: Use this fonn for hardship loans or hardship withdrawals when the "safe harbor" determination of hardship Is used by the Plan. If.. facts and circumstances" method is used for approving withdrawal of any contnbutions under the Plan, additional information would be necessary. o not submit this form to MassMutual. Participant's Name first middle last Social Security No HARSIHP REQUEST t. withdrawal I request a loan of$ due to hardship for the following reason(s): Expenses for Medical Care for myself, my spouse, or my dependent. Purchase of My Primary Residence excluding mortgage payments. Tuition and Related Education Fees including room and board expenses, for the next 12 months for post-secondary education for myself, my spouse, or my dependent. Prevention of Eviction or Foreclosure on my prinwy residence. Expenses for the Repair of amage on my primary residence that would qualify for the casualty deduction under IRC 165. Payment for Burial or Funeral Expenses for my deceased parent, spouse, children or dependents. Please attach documentation evidencing the expense for which this hardship is requested. If the expense is for someone other than the Participant, list the recipient and his or her relationship to the Participant on the expense document. 2. I request an additional amount to pay anticipated federal, state, or local income taxes or excise taxes due to this distribution. 3. I certify that the withdrawauoloan amount requested is not in an amount more than my immediate and heavy fmancial need, due to the reason stated in item (1) above. Consult your tax advisor and the Special Tax Notice for additional details on tax consequences. Note: All distributions and nontaxable loans from this Plan and all other plans maintained by the employer must be exhausted prior to receiving a hardship distribution as long as they are reasonably available (i.e., the loan(s) will not increase the level of need). Consequence of Withdrawal: I understand that my elective deferral and my after-tax contributions to this Plan and all other plans maintained by the Employer may be suspended for a 6-month period or as provided by the terms of the Plan, after the hardship withdrawal is made. SIGNATURE Participant Signature ate Copyright M~~SS~~Chusetts Mutual Lifo Insurance Company, Springfield. MA. All rights reserved. fo RS

2 WITHRAWAL REQUEST Account Number..;;6;.;;0.;;.09;;.;6;;..-1.;....;.1 Sponsor Name Little ixie Community Action Plan Name Little ixie Community Action Agency, Inc. 403(b) Retirement Plan PARTICIPANT INFORMATION Participant's Name first middle last Participant's Address stnlet city state zip Legal State ofresidence ~---~~~~- Iflhe Legal State of Residence is not provided, MassMutual will use lhe state provided in the Mailing Address for state tax purposes. Check if Mailing Address or Legal State of Residence bas changed. Social Security No. Telephone# or Address Marital Status: 0 Married 0 Not Married or Legally Sepmated WITHRAWAL REASON AN OPTIONS Check one box indicating the withdrawal reason. In addition enter the withdrawal amount & payout election TO BE COMPLETE BY YOUR PLAN REPRESENTATIVE: Check only one box for Activity Vesting- Enter the Vested% for each employer contribution source: % (lfmulllp/e vesting schedules please provide vested% for each) TPA Signature: Withdrawal Reason: 0 Hardship Withdrawal* 0 Required Minimum istribution -Tax Year:. 0 Other In-Service Withdrawal- Reason: For hardship wilhdrawals, first complete the appropriate Hardship Statement. A hardship wilhdrawal should not be requested unless other sources (including an in-scivice wilhdmwal or loan from Jhe Plan if you are eligible) are not available. After the date of the wilhdrawal, you may not be able to make any further before-tax or after-tax employee contributions for either a 6-month period or as provided by the terms oflhe Plan. Withdraw Amount: $ or % Type: 0 Net Amount (after taxes) 0 Gross Amount (before taxes) **Net withdrawals not allowed for Required Minimum istributions. If the amount available is less than requested, the amount available will be withdrawn. Only vested money can be withdrawn. If a type is not chosen, the withdrawal will be paid out as a Gross distribution. Payout Election (Select One): If no payout election is made, a Lump Sum Cash payment will be issued to the participant Money will be removed prorated among all sources. Hardships and Required Minimum istributions will be paid out as Lump Sum Cash payments. 0Lump Sum Cash (Participant Payee) 0 IRA/Plan Rollover** 0 Conversion to my ROTH IRA** **NameofRollover~rution /6818/RS IJO.Va.uM""'al hlinmenl Services, PO Box 21906J, Ktuua City MO COMPLETE ALL PAGES For Overnight Mail: MassMutual Retiremmt Services, 430 W 7th St, Kansas City MO MassMuiJial &tiroment &rviou (MMRS) Is a division o{massaduseru Mutual Lifo Insurance Company (MasiMutual) and affiliates.

3 FEERAL INCOME TAX WITHHOLING ELECTION istributions of pre-tax contributions plus interest on All contributions are subject to federal income tax. Non-Hardship Withdrawal- istributions of pre-tax contributions plus interest on All contributions are subject to federal income tax. Federal income tax law requires that 200/o of the taxable amount of the distribution be withheld, unless the payment is directly rolled over to an eligible employer plan or an IRA. ). Please read the Special Tax Notice(s). Contact your tax advisor or the IRS if you have any questions concerning tax withholding. Withholding does not apply as I have directly rolled over the entire taxable payment educt the 20% mandatory federal income tax withholding from the taxable portion of my payment. educt the 20% mandatory federal income tax withholding from the taxable portion of my payment and withhold an additional amount of$ Hardship Withdrawal/ Required Minimum istribution- These withdrawals are not subject to mandatory federal income tax withholding as it is not an eligible rollover distribution. If no election is made, MassMutual will withhold 1 00/o federal income tax. Please read the Special Tax Notice(s). Contact your tax advisor or the IRS if you have any questions concerning tax withholding. o not withhold federal income taxes from the taxable portion of my payment. 0 educt the 100/o mandatory federal income tax withholding from the taxable portion of my payment. 0 educt the 10% mandatory federal income tax withholding from the taxable portion of my payment and withhold an additional amount of$ Note: If you make an election that is not in compliance with federal income tax law, MassMutual will default to the federal income tax requirement based on the withdrawal reason and payout election. STATE INCOME TAX Wfl'HHOLING Contact your tax advisor or your state's tax department if you have any questions concerning state tax withholding. Refer to the State Tax Information document for important infonnation regarding State Withholding in your Legal State of Residence. If you make an election that is not in compliance with your state's regulations, MassMutual will default to your state's requirements. No State Tax Withholding Election I have read the State Tax Information document and I elect to have no state income tax withheld from my payment(s). Voluntary State Income Tax Withholding I have read the State Tax Information document and I elect to have the following voluntary state income tax withheld from my payment(s) (choose one): o % $ (whole dollar amount) Based on my state's tax table fonnula, if applicable (MassMutual will apply the default tax allowance) Additional State Income Tax Withholding I have read the State Tax Information document and I elect to have an additional %or $. (whole dollar amount) state income tax withheld from my payment(s). /6818/RS Ma.rsMututd Retirement Servica, PO Bax , Kamas City MO 641: COMPLETE ALL PAGES For Ovemight Mail: MassMutual Retirement Services, 430 W 7th St, Kansas City MO Mas&Mutval Rertrement Services (MMM) Is a division o[massachwetts Mutval Lifo Insurance Company (MassMUll4al) and ajjillates.

4 METHO OF PAYMENT 0 irect deposit to a bank account of which I am an account holder eposited wlthln 3 business days from date or proc:esslng. This option is NOT available for Rollovers. To elect irect eposit, you must select either Checking or Savlnp 1111d you mwjt provide 11 voided check or copy of a preprinted. account-spec:lftc deposit slip or a bllllk speclflcatlon sheet from your b1111k for vaudatlon. 0Checking Savings Balik NUIICI Bank ABAIRouting (9 digits) Bank AI:COIInl No. Please note that we can only send funds via direct deposit to banks with a valid U.S. routing number. I understand that if I do not fully complete this section or the bank account information I have provided is invalid, a check will be mailed. I understand that a reprocessing fee may be charged to my account if the direct deposit is declined by my fmancial institution. Subsequent withdrawals will be processed in the same manner {up to 180 days from the date of the original distribution) unless I notify MassMutual in writing to distribute the money differently. I also authorize MassMutual to initiate a debit to my account for any overpayment or payments made in error. Send payment by check Allow up to 10 business days for postal service deuvery. SIGNATURES I understand that I have a right to a 30-day election period 1 further acknowledge that I am waiving the 30-day election period by making an affirmative election on this distribution form. 1 understand there may be a charge deducted from my account for each distribution processed and, if all required items are not completed on this form, payment will be delayed. If electing direct deposit, by signing below 1 certify that I am an account holder on the bank account listed above. Participant Plan Adminislrator ----'/ ate =-----'/ ate I / Copyright Massachusetts Mutual Life Insurance Company, Springfield, MA. All rights reserved. /6818/RS IJ MtmMutuallli!tirement Senrica, PO Box , Kllnsas City MO COMPLETE ALL PAGES For Ovemiglrt Mail: Mti!ISMutualRetirementServices, 430 W 7th St, KIUISas City MO McusMutua/ Retirement Serv/CtJS (MMRSJ Is a division ofmtusachwens Mutual Life /ruuranc11 Company (McusMutual) and af!/ltates.

5 WAIVER OF QUALIFIE PRERETIREMENT SURVIVOR ANNUITY Account Number Sponsor Name Little ixie Community Action PARTICIPANT INFORMATION PmncipmtsName_~~ ~~ ~~ first middle ast Social Security No. Spouse's Name fust middle last SPOUSAL CONSENT TOW AIVE THE QUALIFIE PRERETIREMENT SURVIVOR ANNUITY I, the Pmncipm(s spouse, understand I have a right to the Qualified Preretirement Survivor Annuity (QPSA) benefit if my spouse dies before beginning to receive retirement benefits (or, if earlier, before the beginning of the period for which the retirement benefits are paid). I also understand that if the value of the QPSA benefit is below the minimum distribution amount, the plan will pay the benefit to me in one lump sum payment. I agree to give up my right to the QPSA benefits. epending on the Plan's provisions the benefit may be payable in cash, installments or as a QPSA. descn"bed on the second page of this form. I understand that by signing this agreement, I may receive less money than I would have received under the special QPSA payment form and I may receive nothing from the plan after my spouse dies. I understand I do not have to sign this form. I am signing this agreement voluntarily. I also acknowledge that, as the Participmt's spouse, I have a right to limit my consent only to a specific payment election and that I voluntarily elect to relinquish such right. I further understand if I do not sign this form. I will receive the Qualified Preretirement Survivor Annuity upon the death of my spouse. SIGNATURES Spouse's Signature The spouse's signature must be witnessed by tire Plan Administrator or a Notary Public: ----'' ate! Plan Administrator: --;;---:-...,...,~:--:-""'"':':'.---: ;~ Plan Administrator Signature ate -OR Notary PubHc: Notarization of spousal consent can be signed off by a Notary Public or the Plan Administrator. A Notary Seal is not required when signed by the Plan Administrator or when participant resides in one of the folloy.ing states: CT, KY, LA, ME, MI, NJ, NY, RI, vr Before me, the undersigned notary, personally appeared and proved to me through identification documents allowed by law, which were, to be the person who signed the preceding document in my presence and who affirmed to me that they executed the above Consent of Spouse as a free and voluntary act. IN WITNESS WHEREOF, I have signed my name and affixed my official notarial seal this_ day of Witnessed: State: County: My Commission expires: (official signature and seal of notary) Please place Notary Seal/Stamp in the box below: /6191 PLEASE REA SECON PAGE MassMutual Retirement Services, PO Box , Kansas City MO For Ovemlgltt Mall: Mtu.YMutulll Retirement Services, 430 W 7th St, XansiiS City MO MassMIIIutl/ Retirement Services (MMRS) ts a division ofmassa&husetjs Mutual Lifo IMurance Company (MassMUIUQ/) (IJid aj]iliatrj.

6 1. What Is a QuaUfied Preretirement Sunivor Annuity (QPSA)? Your spouse has an account in the Plan. The money in the account that your spouse is entitled to receive is called the vested account You are entitled to a death benefit payable from your spouse's vested account if your spouse dies before beginning to receive retirement benefits (or, if earlier, before the beginning of the period for which termination benefits are paid). You have the right to receive this monthly payment for your life beginning upon your spouse's death. The special death benefit is called a Qualified Preretirement Survivor Annuity (QPSA). The Plan will pay this death benefit in a one-sum cash payment, rather than an mmuity, if the value of the death benefit is less than the Plan's minimum cashout amount (contact the Administrator for details). The Plan may exclude rollover contributions in determining accowlt balance. 2. Can Your Spouse Choose Other Beneficiaries to Receive the Account? Your right to the QPSA benefit provided by federal law C8IUlOt be taken away unless you agree to give up that benefit If you agree, your spouse can choose to have all or a part of the death benefits paid to someone else. The person your spouse chooses to receive the death benefits is usually called the "beneficiary." For example, if you agree, your spouse can have the death benefits paid to his or her children instead of you 3. How Can Your Spouse's Choice of a Loan or istribution Change the Way Benefits are Paid? If you consent to your spouse's request for a loan or distribution from the Plan, the QPSA benefit may be reduced Example: Robin, the participanl, elects to receive a loan.from the Plan in the amowjt of$2,000. To obtain the loan, Marion, Robin's spouse, must cotuent to the loan. If she cotuented and Robin dies soon after the loan, Marion may only be entided to a benefit of the remaining account balance less the outstanding balance of the loan. 4. o You Have to Give Up Your Right to the QuaUfied Preretirement Survivor Annuity? Your choice must be voluntary. It is your personal decision whether you want to give up your right to the mmuity. 5. Can Your Spouse Make Future Changes If You Sign this Form? If you sign this form, you agree that some or all of the accowlt balance may be withdrawn from the Plan as requested by your spouse via a voice response system. the Internet, or an employee activity form. Your spouse cmmot change the withdrawn amowlt after payment is made. 6. Can You Change Your Mind After You Sign this Form? You cmmot change this form after you sign it. Your decision is fmal. 7. What Happens to this Agreement if You Become Separated or ivorced? You may lose your right to the QPSA if you become legally separated or divorced from your spouse even if you do not sign this form. Under such ciroumstance, however, you may be able to get a special court order, called a Qualified omestic Relations Order or "QRO, that specifically protects your rights to receive the QPSA or gives you other benefits under this Plan. If you are thinking about separating or getting a divorce, you should acquire legal advice on your rights to benefits from the Plan. 8. What Should You Know Before Signing this Form? This is a very important decision. Think very carefully about whether you want to sign this form. Before signing, be sure you urulerstand what death benefits you are eligible to receive and the effect of reducing or eliminating the accowlt balance. Be sure to review any applicable employee activity form completed by your spouse and the Sl.llmary Plan escription (SP). For additional information, you may contact the Plan Administrator. Copyright C 2011 Massachuseus Mutual Ufc Insurance Company, Springfield, MA. All rights reserved. f6791 PLEASE REA SECON PAGE MassMuhull Retirement Services, PO Box , Kansas City MO For Ovemlglrt Mall: Ma.uMutulllll4tlrement Servkea, 430 W 7th St, Kt111Sas City MO MassMutual Retirement Services (MMRS) Is a division ofmonochusetts Mutual Ltfe Insurance Company (Mo.uMutual) and affiliates.