Plan Name *

Plan name as shown on your annual 5500 filing or similar.

First Name

Last Name

Plan Administrator Contact Name *

Who is responsible for the day-to-day operation of the 401k plan at your company?

First Name

Last Name

Administrative Contact Phone *

(###)

###

####

Name of Authorized Plan Representative *

Your Name

First Name

Last Name

Date *

Effective date of this change authorization.

MM

DD

YYYY

Affirmation that the individual listed above is an authorized plan representative with the authority to make this change: *

I affirm the information provided in this form is true to the best of my knowledge and that I am authorized by the plan to direct this change.

As an authorized plan representative with the authority to do so, please execute the following instruction: *

Effective immediately, the plan identified above has selected The Dayton Co, Inc., whose business address is 5727 Baker Way NW, STE 101, Gig Harbor, WA 98332 as the Plan's Participant Education Adviser.

Fee for Participant Education Services *

I understand the fee for this service will be .0025, proportionately netted from total plan assets each month.

Authorization to Release Plan Information & Data *

Furthermore, I authorize the release of any and all plan data to The Dayton Co. Inc. and to speak with The Dayton Co. Inc. regarding the plan identified above.

Acknowledgement of Change *

I acknowledge this change directive will be effective upon submission of this request. I also acknowledge and agree to execute any additional documents necessary to process this directive. I furthermore agree to accept and use electronic signature when provided.