Request for Coronavirus- Related DistributionThis form is for Plan 1 and Plan 2 members to use to request a distribution under provisions of the 2020 CARES Act.

Send completed form to:Department of Retirement SystemsPO Box 48380 ꔷ Olympia, WA 98504-8380

www.drs.wa.gov ꔷ 800.547.6657360.664.7000 ꔷ TTY: 711

DRS MS 470 4/20*DRSMS470*

Customer InformationName (Last, First, Middle) Social Security Number

Date of Birth (mm/dd/yyyy) Phone Number Alternate Phone Number

Request for Distribution

I am requesting a coronavirus-related distribution in the amount of $___________________________________________.

Certification and Signature

I certify that I qualify for a coronavirus-related distribution for one or more of the following reasons: • I have been diagnosed with COVID-19 • My spouse or dependent has been diagnosed with COVID-19 • I am experiencing/have experienced adverse financial consequences as a result of being quarantined, furloughed, laid off, reduced work hours, inability to work due to lack of child care because of COVID-19, or the closing or reducing hours of a business I own or operate due to COVID-19

I further acknowledge that: The amount of coronavirus-related distribution(s) I obtain from DRS and any other retirement plans from my employer is limited to $100,000 and that I am not exceeding this limit; DRS is relying on my certification that I qualify for a coronavirus-related distribution; and this distribution is subject to ordinary income taxes. Unless I change my withholding by submitting a W-4P, DRS will withhold 10% for federal taxes. To the extent otherwise applicable, I understand that the CARES Act waives the 10% early withdrawal penalty tax for coronavirus-related distributions, and that the Act also permits the federal tax on the distribution to be apportioned over a three-year period. DRS has advised me to talk with my personal tax consultant about how this distribution will affect my individual taxes and what repayment rights I have under the CARES Act.

I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

Signature Date

The Coronavirus Aid, Relief and Economic Security Act of 2020 (CARES Act) permits qualifying members to receive a coronavirus-related distribution of up to $100,000. Individuals making a request must certify that they qualify for a distribution under provisions of the Act. Please note that coronavirus-related distributions are not eligible rollover distributions.

Submit this form with the Plans 1 and 2 Request for Refund of Retirement Contributions form (DRS MS 287). Unless you request otherwise, DRS will withhold 10% of your distribution for federal tax purposes. If you wish to change your withholding, please submit an IRS Form W-4P along with your request for distribution/withdrawal forms.

Your Social Security number is needed so DRS can report to the IRS any funds paid to you. DRS will not disclose your Social Security number unless required to do so by law. See IRC sections 6041(a) and 6109.