Participant S Waiver of 30-Day Notice Requirement

111A1m1e1r1i1c1a1n1 1P1e1n1s1i1o1n1 1C1o1r1p1o1r1a1t1i1o1n1 111317151 1P1L1A1I1N1F1I1E1L1D1 1A1V1E1N1U1E1 1 W1A1T1C1H1U1N1G1,1 1N1E1W1 1J1E1R1S1E1Y1 10171016191 1(1910181)1 1715171-151115111 1 1F1a1c1s1i1m1I1l1e1 1(1910181)1 1715171- 191614141 1 1 1P1L1A1N1 1S1P1O1N1S1O1R1 1Q1U1E1S1T1I1O1N1N1A1I1R1E1 1 1N1A1M1E1 1O1F1 1B1U1S1I1N1E1S1S1: 1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_ 1_1_1_1_1_1_1_1_1_1_1 1B1U1I1S1N1E1S1S1 1A1D1D1R1E1S1S1:1_1_1_1_1_1_1_1_1_1_1_1______EXPRESS SERVICE ADDRESS:______(real location, if different) ______TELEPHONE: (_____) ______-______FAX: (_____) ______-______E.I.N.: ______- ______(tax number) STATE of INC. (business):______DATE BUSINESS BEGAN (or D.O. Inc.):______FISCAL Year-end:____/____ (month/day) TYPE OF BUSINESS ENTITY: Reg. Corp. P.A. LLC Sole Prop. Exempt Sub-S P.C. LLP Partnership Govnmt [ ]Single-Employer Plan [ ]Controlled Group [ ]Church Group [ ]Affiliated Service Org. [ ]Government Org.

NATURE of BUSINESS: ______COUNTY: ______Numeric Business Code: ______if known COMPANY OFFICERS: President: ______Secretary: ______Vice Pres: ______Other: ______

COMPANY OWNERS: ______% (and percent owned) ______% ______% ______%

If this is a Controlled Group, or an Affiliated Service Organization, please provide information on those other companies (Relationship, Ownership, Number of employees, Business, Plans in effect).

American Pension Corporation

NAME of ATTORNEY or ACCOUNTANT: ______Telephone: ______Fax: ______Address: ______

Plan Information, if determined NAME OF PLAN: ______

03bf83310424cfe71258648687df6690.doc Page 1 of 2 TYPE OF PLAN: ______401(a) 401(k) Safe-Harbor Simple-I.R.A. 403(a) 403(b) Who will sign 5500 for the Employer: ______Title: ______Who will sign 5500 as Plan Administrator: ______Title: ______Employer Contact for Year-end Information: ______Title: ______Email addr: ______Tel Ext: ______PLAN'S EFFECTIVE DATE: ____/____/______PLAN'S YEAR-END:______/______(month/day) PLAN NUMBER: ______Plan's T.I.N. ______-______(tax number) ELIGIBILITY: Age______Service______Exclusions: ______Vesting Entry Dates: ______Other: _____% 1 _____% 2 _____% Hours or other Requirement for a Contribution: ______3 _____% 4 _____% Ret. Age: ______Years part: ______Other Option: ______5 _____% 6 _____% Loans: Rate ______% Number Allowed: ______Other: ______7 _____% In-service Distributions: ______MATCH: Matching Percent: ______% Maximum Percent of Salary Matched: ______% $______ALLOCATION FORMULA: ______Investment Program: ______Primary Investment Representative: ______Tel: ______Fax: ______TRUSTEES:______S.S. # ______S.S. # ______S.S. # ______

Last Plan Document Sponsor (by): ______Approval Letter Date: ______Other Plans in effect: ______OTHER INFO: ______

2 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222222222222222222222222222222222222222222222222222222222222222 222222222222222222222222

03bf83310424cfe71258648687df6690.doc Page 2 of 2