401k Rollover Request

To: Plan Administrator of the Jim's 401k plan (the "Plan").

From: Javier Espinoza 8 Hayes St San Rafael, CA 94901 Social Security Number: 123456780 After reviewing the notices that you have provided to me regarding distributions and income taxes, I hereby elect a "direct rollover" of my entire vested account balance in the Plan. Further, I hereby request that you transfer my account balance as a direct rollover to the IRA or the Plan designated as follows ( the "Receiving Plan"). I represent that the Receiving Plan is a proper recipient plan for a direct rollover. My account balance should be sent to the address as shown. Name of IRA: Name of Trustee or Custodian: Address: James Smith Bill George 555 Pleasent St Apple City, CA 94999

I hereby consent to an immediate distribution of my vested account balance, and I waive any unexpired portion of any minimum notice period that might otherwise apply to this distribution.

Effective Date: February 16, 2012

_______________________________________ Javier Espinoza

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