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INSTRUCTION FORM <br />In order to receive a distribution from the Settlement, an authorized representative of the Plan <br />needs to complete this Instruction Form. Please fill this out and return it to the following address <br />no later than December 1, 2014: <br />Strategic Claims Services <br />Attn: ING ERISA Settlement <br />P.O. Box 230 <br />600 N. Jackson Street, Suite 3 <br />Media, PA 19063 <br />I. Information About the Plan <br />Name of Plan: <br />Plan Tax ID Number: <br />Group Number: <br />Name of Authorized Plan Fiduciary: <br />Mailing Address: <br />City, State, Postal Code: <br />II. Instructions to the Settlement Administrator <br />Question 1: Does the Plan currently have a group variable annuity contract or group funding <br />agreement with ILIAC and/or use ILIAC as its 401(k) or 401(a) service provider? <br />Yes No (Circle one) <br />If the answer is no, proceed to Question 2. If you answer "Yes" and submit this Instruction <br />Form, please be advised that you are instructing the Settlement Administrator on behalf of the <br />Plan to distribute any Settlement proceeds by issuing a check payable to the Plan Sponsor. The <br />Plan hereby instructs the Settlement Administrator to distribute any Settlement proceeds by a <br />check payable to the Plan Sponsor. The check should be made payable to: <br />and mailed to the following address: <br />Important note: The proceeds may only be used to pay for or defray reasonable plan expenses. <br />You cannot deposit such amount to the Plan or distribute such amount to the Plan's participants <br />because such a deposit/distribution could not be accomplished in a practical way under the <br />circumstances. Check with your legal advisor or Class Counsel if you have questions about how <br />the proceeds may be used. <br />127 <br />