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Question 4: If you answered "no" to questions 1 and 2, the plan is likely not eligible to receive <br />any money from the Settlement because it does not appear that the plan maintained a contractual <br />relationship with ILIAC that renders it eligible to participate in the Settlement. Please explain <br />why you believe the plan is entitled to some distribution (attach additional sheets if necessary, as <br />well as any documentation to support your belief). <br />III. Certification <br />As authorized fiduciary for the above -identified plan, I hereby authorize and direct the Settlement <br />Administrator to utilize the allocation method selected above in applying the Settlement proceeds <br />conveyed to the plan from Healthcare Strategies, Inc., et al. v. ING Life Insurance and Annuity <br />Co., et al., or, if applicable, to forward the Settlement proceeds as instructed in response to <br />Question 3. <br />Signature of Authorized Plan Fiduciary: <br />Print Name of Authorized Plan Fiduciary: <br />Name of Payee for Settlement Check (from Question 1 or 3, as applicable): <br />Address To Which Settlement Check Should Be Sent (from Question 1 or 3, as applicable): <br />Date: <br />Telephone Number(s) if Any Questions: <br />Email Address(es): <br />3 <br />129 <br />