Customer Service Assistant Manager

FOR YOUR RECORDS

As your employer's Plan Administrator, U.S. OMNI & TSACG

Compliance Services, is confirming the submission of your online transaction. The information pertaining to your request has been forwarded to our team for processing and you will be notified by email as soon as possible of the outcome of this review. Please retain a copy of the attached Summary Confirmation as it outlines your request and includes a transaction reference number. If approved, an Approval Certificate will be generated and provided to you by email. As a reminder, you will need to forward any paperwork the investment provider may require with the approval certificate, after receiving the email notice of approval.

ODS Transaction ID: 112*******

P.O. Box 4037

Fort Walton Beach, FL 32549

www.tsacg.com

403(b) PLAN DISBURSEMENT REQUEST FORM - Summary Confirmation As your employer's Plan Administrator, U.S. OMNI & TSACG Compliance Services, is confirming the submission of your online transaction.

IMPORTANT NOTICE: Read all the information on this form. The information pertaining to your request has been forwarded to our team for processing and you will be notified by email as soon as possible of the outcome of this review. If approved, an Approval Certificate will be generated and provided to you by email. As a reminder, you will need to forward any paperwork the investment provider may require with the approval certificate, after receiving the email notice of approval.

ODS TRANSACTION ID: 112******* DATE SUBMITTED: 04/25/2023 8:55:58 AM CST TRANSACTION TYPE: Distribution - Separated From

Service

THIS IS NOT AN APPROVAL

Employee Information:

Full Name: Richard E Kimes

Address: 1773 Wayne Rt.V City ST Zip: piedmont, Mo 63957 Phone: 573-***-**** Alternate Phone: Email: ********@*****.*** SSN: XXX-XX-3055 Date of Birth: 04/08/1974

Investment Provider Agent Information:

There is a financial advisor/representative associated with this transaction: No Distributing Account Information:

Employer State: MO Employer Name: Clearwater R-1 School District Investment Provider Company: North American Company for Life

Account Number: 800******* Amount/Percentage Requested: 100.00%

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