Name *

First Name

Last Name

Phone

(###)

###

####

Date *

MM

DD

YYYY

Affirmation that the Individual listed above is an authorized plan representative with 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 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 our plan representative in accordance to the advisory form instructions.

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.