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If the checks are voided, the proper form of payment is required in order for the proceeds to be transferred to my account. If I do not wish for my funds to be transferred or have them returned, I authorize United American Insurance Company to contact the IRS and have the return of the funds returned. Upon completion of the tax obligations, any balance of the withdrawal which remains undistributed shall be returned to me in equal installments. I hereby expressly authorize, certify and attest the following information on the face of the checks and deposit slips in accordance with applicable tax laws: I have read and understood the provisions of the United States Internal Revenue Code and this document, and have been informed that: A) I have the legal responsibility to file income tax returns and pay taxes; and B) There may be penalties due to failure to file a return or payment of tax, including, but not limited to, penalties that will be added to the tax on the withdrawal. Furthermore, I agree that my receipt of the items may assist me in completing my required tax returns. Furthermore, I further certify and attest below under penalty of perjury, that I fully understand the foregoing and understand that my obligation to file income tax returns and pay taxes is dependent upon my ability to pay the taxes due. Furthermore, I understand that I must mail in the verification of employment information, signed, dated and sent, as noted in this document, by me to verify my eligibility for a retirement benefit, upon which the company may make deductions by deducting from its tax obligation. In any case, I acknowledge that the company may make no deduction for any tax obligation due from United American Insurance Company based on my absence from the United States through no fault of my own, or on the ground that my whereabouts are unknown. I understand and agree that the deduction from any amount deposit into my account will be considered for tax purposes a reimbursement of an employer tax liability which is based on my participation in the unemployment compensation plan. I agree, under penalty of perjury, that I will provide the required information in the future in order for me to obtain a withdrawal. For details or to download this form, click here. A.S.E.S C.G.P. S.C.L.A. I.P.O. I.R.C.C. D.O.L. P.O.P. B-K J.I.C.L.

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