Investing involves risk, including possible loss of principal. Qualifi ed retirement plans, deferred compensation plans and individual retirement ac-counts are all diff erent, including fees and when you can access funds. Assets rolled over from your account(s) may be subject to surrender charges, other fees and/or a 10% tax penalty if withdrawn before age 59½. Neither Nationwide nor any of its representatives give legal or tax advice. Please contact your legal or tax advisor for such advice.

Plan representatives are registered representatives of Nationwide Investment Services Corporation, member FINRA.

Important Notes

• When you open a new account, your investments are deposited into the “Asset Allocation Index Fund Moderate” until you request a diff erent fund option.

• If you already have an account, your cashable leave credits will deposit into the investment choices you have on fi le.

• You can change your investment selection any time online, in person, or over the phone.

• Notify your personnel offi ce of your decision to transfer your cashable leave credits at least 30 days prior to your separation date.

• If you’re approved for Catch-Up contributions, provide a copy of your approved Catch-Up Worksheet to your personnel offi ce. For more information, review the 457 Traditional Catch-Up booklet online, or call (866) 566-4777 to request that one be mailed to you.

One last chance to PAY YOURSELF FIRST.Unused accumulated leaveWhen you retire, your department will issue a payment to you for the value of your unused accumulated leave, and other cashable leave credits. Why not ‘pay yourself fi rst’ and transfer this money into your Savings Plus account? Talk to your personnel offi ce today to fi nd out the value of your cashable leave credits.

Catch-up optionYou can play “catch-up” to make up for the years you didn’t contribute the maximum amount allowed to your 457 plan. The catch-up provision may allow you to double your contribution limit to the 457 plan for up to 3 consecutive years, and you may be eligible to start as early as age 47! Use your separation pay at retirement with catch-up to maximize your deferral!

Even more options for year-end retireesGenerally, if you separate service on or after November 1st, you may use your separation pay + catch-up to defer into the following tax year to maximize the benefi t to your Savings Plus account.

Start today 866-566-4777

or fax to 877-677-4329

sppforu.com

Mail the original form to:Nationwide Retirement SolutionsP.O. Box 182797Columbus, OH 43218-2797

Overnight mail to:Nationwide Retirement Solutions5900 Parkwood PlaceDublin, OH 43016

or

NRM-8403CA-CA.2 (08/12)

Last Name, First Name, MI Social Security Number (SSN)

Mailing Address Date of Birth (mm/dd/yyyy)

City, State, ZIP Code Separation Date (mm/dd/yyyy)

Daytime Telephone Number Alternate Contact Number( )

SECTION I–Participant Information

SECTION II–Optional Enrollment InformationComplete if you need to open an account. If not, skip to Section III.A. Check the plan in which you wish to enroll. You may enroll in one or both plans.

401(k) or 457B. (Optional) If you enroll in a new account, and you wish to contribute prior to separation, enter the amount you wish to contribute per month. The minimum

monthly contribution amount is $50. Leave blank if you don’t want to contribute prior to separation.

C. Payroll warrant/check issued by (check on box only):

State Controller’s Offi ce District Agricultural Assoc. (Fairs) Assembly Rules Committee CDFA/Marketing Council Senate Rules Committee Legislative Analyst Offi ce

D. Enter pay frequency:

Monthly Semi-Monthly

SECTION III–Contribution Information

SECTION IV–Participant Certi cationI authorize Savings Plus to open an account for me according to my request as outlined in Section II of this form.

I request a contribution of lump sum separation pay in accordance with the Plan Document, Internal Revenue Code, and my election above. I take full responsibility for providing my request to my personnel offi ce 30 days prior to my separation date and understand the terms and conditions of deferring all or a portion of my lump sum separation pay. If applicable, I have attached a copy of my approved Savings Plus Catch-Up Worksheet.

I understand that the State of California has the authority to approve or reject this request. I hereby certify under penalty of perjury that the information on this form is true and accurate to the best of my knowledge.

Signature Date

State of CaliforniaNRM-4074CA.10 (06/12)

Lump-Sum Separation Pay Transfer

( )

Make two copies. Send the original to personnel and keep a copy for yourself (Mail or fax a copy to Savings Plus if Section ii-A is checked for enrollment).Submit to personnel at least 30 days prior to separation.

Privacy Statement: The Information Practices Act of 1977 (Civil Code Section 1798.17) and the federal Privacy Act (Public Law 93-579) require that this notice be provided when collecting personal information from individuals. Information requested on this form is used by Savings Plus for purposes of identifi cation and account processing. You must furnish all the information requested on this form. Failure to provide the information may result in the action requested not being processed.

401(k) Contribution Amount 457 Contribution Amount

$________________ $________________

A. Write the amount you will have contributed to each plan for this tax year when you separate. Don’t include the lump sum separation pay you’ll contribute after you separate. 401(k) $_____________________ 403(b) $__________________________ 457 $___________________________B. Write the amount you plan to contribute from your lump sum separation pay below. The total amount in section A and section B cannot exceed the maximum annual limits. Contributions to the 403(b) must be included in calculating 401(k) limits. See our website for details.

Tax Year 401(k) 457

Year_________ Year_________

$_______________ $_______________

$_________ $_________

SECTION V–Personnel Of ce Use OnlyRefer to SCO Personnel Letters applicable to Lump Sum Pay for instructions on completing the separation PAR. Attach this request with a copy of the separation PAR and, if applicable, the approved Savings Plus Catch-Up Worksheet from the employee. Retain a copy with the employee fi le. Do not submit a copy to Savings Plus.

California Exposition (CalExpo)