Transfer or Direct Rollover RequestReturn completed form to:Certified Benefits Corp, 1111 Douglas Avenue, Altamonte Springs, FL 327141.Participant InformationNameTelephone NumberAddressSocial Security NumberCityStateZipName of Present EmployerDate of BirthDate of HireType of Account Established at Certified Benefits Corp:2. 401(k) 403(b)Account to be TransferredI authorize my present Custodian/Trustee of my IRA, or my present employer of my retirement plan, to send the assets indicated in Part 3 below directlyto my account with Certified Benefits Corp, Third Party Administrator (TPA).Name of Present Custodian or TrusteeAddressCityPhone NumberCurrent Account Number(s)Type of Account Being Transferred:3.401(k)State403(b)457ZipTraditional IRAPayment Information and InstructionsPlease attach a copy of your most recent statement from the account you wish to transfer or rollover.I authorize and direct my present Custodian/Trustee to send my assets as follows: Immediately liquidate all assets and send the cash proceeds Partial Distribution of $_____________(transfer or rollover amount) Attached is my rollover contribution check in the amount of: $________________.Make check payable to “The Rock of Central Florida, Inc. 401(k) Profit Sharing Plan and Trust FBO Participant (account holder’s name)”Mail proceeds to:4.Certified Benefits Corp1111 Douglas AvenueAltamonte Springs, FL 32714Signature and CertificationI certify that I have established an account with Certified Benefits Corp (TPA), for which Fidelity Investments NFS Corp. is the Custodian. I understandthat I am responsible for determining my eligibility for all transfers or rollovers. I agree to hold the TPA and Custodian harmless against any and allsituations arising from an ineligible transfer or direct rollover. I acknowledge that the TPA and Custodian cannot provide legal advice, and I agree toconsult with my own tax professional for advice.Participant SignatureDateEmployer AuthorizationDateCertified Benefits Corp is an affiliate of Certified Financial Group, Inc.Planning Tomorrow….Today! is a registered federal trademark of Certified Financial Group, Inc.
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