WAIVER OF THIRTY (30) DAY WAITING PERIOD

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Employer and Plan: Name of Plan:

Information: Name of Employer:

Address:

City: State: ZIP:

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I, , understand that I have thirty (30) days following my receipt of the Special Tax Notice Regarding Payments to consider my options with respect to distributions from the [Firm Name] 401(k) Plan. I have fully considered this matter and have made my distribution election. I hereby waive the thirty (30) days delay requirements, and request that my distribution be made as soon as possible.

Participant Signature

STATE OF )

) SS:

COUNTY OF )

Before me, a Notary Public in and for said County and State, did personally appear who, being duly sworn upon his/her oath and after affirming under penalties of perjury that the foregoing statements were true, did acknowledge execution of the foregoing Waiver of Thirty Day Waiting Period this day of .

Notary Signature:

Printed:

My Commission Expires: County of Residence: