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The Internal Revenue Service has advised the State Retirement Agency (the "Agency") that it must provide you with the Safe Harbor Tax Notice entitled "SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS" no earlier than 90 days and no later than 30 days before a payment is made to you. If, after receiving the Safe Harbor Tax Notice, you affirmatively choose to make or not make a direct rollover, then the distribution may be made to you even if the 30 day period has not expired.

So that you are not required to wait 30 days after receipt of the Tax Notice, the Agency will make the distribution in accordance with Agency procedures to you or to the trustee of your traditional IRA or Eligible Employer Plan upon receipt of this form signed by you to evidence your agreement to the following matters:

1.That you have received the Safe Harbor Tax Notice entitled "SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS" from the Agency;

2.That you have had an opportunity to review it with your tax advisor, accountant, attorney or the IRS and understand your options with respect to receipt of a distribution from the Agency at this time;

3.That you affirmatively chose to make or not make a direct rollover by executing the appropriate Agency form; and

4.That you request the Agency to make a distribution of the funds in accordance with your instructions and you understand that the payment may be made less than 30 days after you received the Safe Harbor Tax Notice.

If you have any questions about this form, before signing it, telephone a retirement benefits counselor at 410-625-5555 or toll free at 1-800-492-5909.

ALL OF THE ABOVE IS AS AGREED:

Signature:Date:

Address: