Exhibit 10.16

Ameriana Bank, SB

Supplemental Retirement Plan

 

AMERIANA BANK, SB

SUPPLEMENTAL RETIREMENT PLAN

THIS SUPPLEMENTAL RETIREMENT PLAN (this “Agreement”) is adopted this 30th day of
December, 2008, by and between AMERIANA BANK, SB, a state chartered savings bank
located in New Castle, Indiana (the “Bank”), and Richard Hennessey (the
“Director”).

The purpose of this Agreement is to provide specified benefits to the Director,
a member of a select group who contributes materially to the continued growth,
development and future business success of the Bank.

Article 1

Definitions

Whenever used in this Agreement, the following words and phrases shall have the
meanings specified:

 

1.1 “Account Value” means the amount shown on Schedule A under the heading
Account Value. The parties expressly acknowledge that the Account Value may be
different than the liability that should be accrued by the Bank, under Generally
Accepted Accounting Principles (“GAAP”), for the Bank’s obligations under this
Agreement. The Account Value on any date other than the end of a Plan Year shall
be determined by adding the prorated increase attributable for the current Plan
Year to the Account Value for the previous Plan Year.

 

1.2 “Beneficiary” means each designated person or entity, or the estate of the
deceased Director, entitled to any benefits upon the death of the Director
pursuant to Article 4.

 

1.3 “Beneficiary Designation Form” means the form established from time to time
by the Plan Administrator that the Director completes, signs and returns to the
Plan Administrator to designate one or more Beneficiaries.

 

1.4 “Board” means the Board of Directors of the Bank as from time to time
constituted.

 

1.5 “Change in Control” means a change in the ownership or effective control of
the Bank, or in the ownership of a substantial portion of the assets of the
Bank, as such change is defined in Code Section 409A and regulations thereunder.

 

1.6 “Code” means the Internal Revenue Code of 1986 as amended from time to time.

 

1.7 “Early Termination” means Separation from Service before attainment of
Normal Retirement Age except when such Separation from Service occurs within
twenty-four (24) months following a Change in Control or due to death.

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Ameriana Bank, SB

Supplemental Retirement Plan

 

 

1.8 “Effective Date” means January 1, 2008.

 

1.9 “Holding Company” means AMERIANA BANCORP.

 

1.10 “Normal Retirement Age” means the Director’s age seventy (70).

 

1.11 “Normal Retirement Date” means the later of Normal Retirement Age or
Separation from Service.

 

1.12 “Plan Administrator” means the Board or such committee or person as the
Board shall appoint.

 

1.13 “Plan Year” means each twelve (12) month period commencing on January 1 and
ending on December 31 of each year. The initial Plan Year shall commence on the
Effective Date of this Agreement and end on the following December 31.

 

1.14 “Schedule A” means the schedule attached to this Agreement and made a part
hereof. Schedule A shall be updated upon a change in any of the benefits under
Articles 2 or 3.

 

1.15 “Separation from Service” means termination of the Director’s service with
the Bank for reasons other than death. Whether a Separation from Service has
occurred is determined in accordance with the requirements of Code Section 409A
based on whether the facts and circumstances indicate that the Bank and Director
reasonably anticipated that no further services would be performed after a
certain date or that the level of bona fide services the Director would perform
after such date (whether as an employee or as an independent contractor) would
permanently decrease to no more than twenty percent (20%) of the average level
of bona fide services performed (whether as an employee or an independent
contractor) over the immediately preceding thirty-six (36) month period (or the
full period of services to the Bank if the Director has been providing services
to the Bank less than thirty-six (36) months).

Article 2

Distributions During Lifetime

 

2.1 Normal Retirement Benefit. Upon Separation from Service after attaining
Normal Retirement Age, the Bank shall distribute to the Director the benefit
described in this Section 2.1 in lieu of any other benefit under this Article.

 

  2.1.1 Amount of Benefit. The annual benefit under this Section 2.1 is Twenty
Five Thousand Five Hundred Dollars ($25,500).

 

  2.1.2 Distribution of Benefit. The Bank shall distribute the annual benefit to
the Director in a lump sum commencing on the first day of the month following
Separation from Service. The annual benefit shall be distributed to the Director
for fifteen (15) years.

 

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Ameriana Bank, SB

Supplemental Retirement Plan

 

 

2.2 Early Termination Benefit. If Early Termination occurs, the Bank shall
distribute to the Director the benefit described in this Section 2.2 in lieu of
any other benefit under this Article.

 

  2.2.1 Amount of Benefit. The benefit under this Section 2.2 is the vested
Account Value determined as of the end of the month preceding Separation from
Service. This benefit is determined by vesting the Director in ten percent
(10%) of the Account Value for the first Plan Year, and an additional ten
percent (10%) of said amount for each succeeding year thereafter until the
Director becomes one hundred percent (100%) vested in the Account Value.

 

  2.2.2 Distribution of Benefit. The Bank shall distribute the benefit to the
Director in one hundred eighty (180) equal monthly installments commencing on
the first day of the month following Normal Retirement Age.

 

2.3 Change in Control Benefit. If a Change in Control occurs followed within
twenty-four (24) months by Separation from Service prior to Normal Retirement
Age, the Bank shall distribute to the Director the benefit described in this
Section 2.3 in lieu of any other benefit under this Article.

 

  2.3.1 Amount of Benefit. The benefit under this Section 2.3 is one hundred
percent (100%) of the Account Value.

 

  2.3.2 Distribution of Benefit. The Bank shall distribute the benefit to the
Director in a lump sum within thirty (30) days following Separation from
Service.

 

2.4 Distributions Upon Taxation of Amounts Deferred. If, pursuant to Code
Section 409A, the Federal Insurance Contributions Act or other state, local or
foreign tax, the Director becomes subject to tax on the amounts deferred
hereunder, then the Bank may make a limited distribution to the Director in a
manner that conforms to the requirements of Code section 409A. Any such
distribution will decrease the Director’s benefits distributable under this
Agreement.

 

2.5 Change in Form or Timing of Distributions. For distribution of benefits
under this Article 2, the Director and the Bank may, subject to the terms of
Section 8.1, amend this Agreement to delay the timing or change the form of
distributions. Any such amendment:

 

  (a) may not accelerate the time or schedule of any distribution, except as
provided in Code Section 409A;

 

  (b) must, for benefits distributable under Section 2.2, be made at least
twelve (12) months prior to the first scheduled distribution;

 

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Ameriana Bank, SB

Supplemental Retirement Plan

 

 

  (c) must, for benefits distributable under Sections 2.1, 2.2 and 2.3, delay
the commencement of distributions for a minimum of five (5) years from the date
the first distribution was originally scheduled to be made; and

 

  (d) must take effect not less than twelve (12) months after the amendment is
made.

Article 3

Distribution at Death

 

3.1 Death During Active Service. If the Director dies prior to Separation from
Service, the Bank shall distribute to the Beneficiary the benefit described in
this Section 3.1. This benefit shall be distributed in lieu of any benefit under
Article 2.

 

  3.1.1 Amount of Benefit. The benefit under this Section 3.1 one hundred
percent (100%) of the Account Value determined as of the date of the Director’s
death.

 

  3.1.2 Distribution of Benefit. The Bank shall distribute the benefit to the
Beneficiary in a lump sum on the first day of the fourth month following the
Director’s death. The Beneficiary shall be required to provide the Director’s
death certificate to the Bank.

 

3.2 Death During Distribution of a Benefit. If the Director dies after any
benefit distributions have commenced under this Agreement but before receiving
all such distributions, the Bank shall distribute to the Beneficiary the
remaining benefits at the same time and in the same amounts they would have been
distributed to the Director had the Director survived.

 

3.3 Death Before Benefit Distributions Commence. If the Director is entitled to
benefit distributions under this Agreement but dies prior to the date that
commencement of said benefit distributions are scheduled to be made under this
Agreement, the Bank shall distribute to the Beneficiary the same benefits to
which the Director was entitled prior to death, except that the benefit
distributions shall be paid in the manner specified in Section 3.1.2 and shall
commence on the first day of the fourth month following the Director’s death.

Article 4

Beneficiaries

 

4.1 In General. The Director shall have the right, at any time, to designate a
Beneficiary to receive any benefit distributions under this Agreement upon the
death of the Director. The Beneficiary designated under this Agreement may be
the same as or different from the beneficiary designated under any other plan of
the Bank in which the Director participates.

 

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Ameriana Bank, SB

Supplemental Retirement Plan

 

 

4.2 Designation. The Director shall designate a Beneficiary by completing and
signing the Beneficiary Designation Form and delivering it to the Plan
Administrator or its designated agent. If the Director names someone other than
the Director’s spouse as a Beneficiary, the Plan Administrator may, in its sole
discretion, determine that spousal consent is required to be provided in a form
designated by the Plan Administrator, executed by the Director’s spouse and
returned to the Plan Administrator. The Director’s beneficiary designation shall
be deemed automatically revoked if the Beneficiary predeceases the Director or
if the Director names a spouse as Beneficiary and the marriage is subsequently
dissolved. The Director shall have the right to change a Beneficiary by
completing, signing and otherwise complying with the terms of the Beneficiary
Designation Form and the Plan Administrator’s rules and procedures. Upon the
acceptance by the Plan Administrator of a new Beneficiary Designation Form, all
Beneficiary designations previously filed shall be cancelled. The Plan
Administrator shall be entitled to rely on the last Beneficiary Designation Form
filed by the Director and accepted by the Plan Administrator prior to the
Director’s death.

 

4.3 Acknowledgment. No designation or change in designation of a Beneficiary
shall be effective until received, accepted and acknowledged in writing by the
Plan Administrator or its designated agent.

 

4.4 No Beneficiary Designation. If the Director dies without a valid beneficiary
designation, or if all designated Beneficiaries predecease the Director, then
the Director’s spouse shall be the designated Beneficiary. If the Director has
no surviving spouse, any benefit shall be paid to the Director’s estate.

 

4.5 Facility of Distribution. If the Plan Administrator determines in its
discretion that a benefit is to be distributed to a minor, to a person declared
incompetent or to a person incapable of handling the disposition of that
person’s property, the Plan Administrator may direct distribution of such
benefit to the guardian, legal representative or person having the care or
custody of such minor, incompetent person or incapable person. The Plan
Administrator may require proof of incompetence, minority or guardianship as it
may deem appropriate prior to distribution of the benefit. Any distribution of a
benefit shall be a distribution for the account of the Director and the
Beneficiary, as the case may be, and shall completely discharge any liability
under this Agreement for such distribution amount.

Article 5

General Limitations

 

5.1

Forfeiture. The Director shall forfeit any non-distributed benefits under this
Agreement if during the term of this Agreement and within five (5) years
following a Separation from Service, the Director, directly or indirectly,
engages in or becomes an owner, agent, officer, director or shareholder, as
defined hereinafter, of any business which competes with any of the businesses
conducted by the Bank, the Holding Company or any of the subsidiaries of either
in any of the following states, to-wit: Indiana, Ohio, Kentucky,

 

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Ameriana Bank, SB

Supplemental Retirement Plan

 

 

 

Illinois and/or Michigan. The Bank and the Director agree that the term of this
covenant not to compete and the geographic area described here are reasonable
given the nature of the businesses conducted by the Bank, the Holding Company
and their subsidiaries and given the plans for the conduct of business made by
the Bank in its strategic plans. In the event the Director breaches this
provision, the Bank may cancel all benefits provided herein upon giving the
Director twenty one (21) days written notice and an opportunity to cure said
breach. For purposes of this section, the Director shall be deemed a shareholder
if the Director acquires five percent (5%) or more of any publicly traded or
privately held entity that competes with the Bank as aforesaid.

Article 6

Administration of Agreement

 

6.1 Plan Administrator Duties. The Plan Administrator shall administer this
Agreement according to its express terms and shall also have the discretion and
authority to (i) make, amend, interpret and enforce all appropriate rules and
regulations for the administration of this Agreement and (ii) decide or resolve
any and all questions, including interpretations of this Agreement, as may arise
in connection with this Agreement to the extent the exercise of such discretion
and authority does not conflict with Code Section 409A.

 

6.2 Agents. In the administration of this Agreement, the Plan Administrator may
employ agents and delegate to them such administrative duties as the Plan
Administrator sees fit, including acting through a duly appointed
representative, and may from time to time consult with counsel who may be
counsel to the Bank.

 

6.3 Binding Effect of Decisions. Any decision or action of the Plan
Administrator with respect to any question arising out of or in connection with
the administration, interpretation or application of this Agreement and the
rules and regulations promulgated hereunder shall be final and conclusive and
binding upon all persons having any interest in this Agreement.

 

6.4 Indemnity of Plan Administrator. The Bank shall indemnify and hold harmless
the Plan Administrator against any and all claims, losses, damages, expenses or
liabilities arising from any action or failure to act with respect to this
Agreement, except in the case of willful misconduct by the Plan Administrator.

 

6.5 Bank Information. To enable the Plan Administrator to perform its functions,
the Bank shall supply full and timely information to the Plan Administrator on
all matters relating to the date and circumstances of the Director’s death, or
Separation from Service, and such other pertinent information as the Plan
Administrator may reasonably require.

 

6.6 Annual Statement. The Plan Administrator shall provide to the Director,
within one hundred twenty (120) days after the end of each Plan Year, a
statement setting forth the benefits to be distributed under this Agreement.

 

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Ameriana Bank, SB

Supplemental Retirement Plan

 

 

Article 7

Claims And Review Procedures

 

7.1 Claims Procedure. The Director or Beneficiary (“claimant”) who has not
received benefits under this Agreement that he or she believes should be
distributed shall make a claim for such benefits as follows:

 

  7.1.1 Initiation – Written Claim. The claimant initiates a claim by submitting
to the Plan Administrator a written claim for the benefits. If such a claim
relates to the contents of a notice received by the claimant, the claim must be
made within sixty (60) days after such notice was received by the claimant. All
other claims must be made within one hundred eighty (180) days of the date on
which the event that caused the claim to arise occurred. The claim must state
with particularity the determination desired by the claimant.

 

  7.1.2 Timing of Plan Administrator Response. The Plan Administrator shall
respond to such claimant within ninety (90) days after receiving the claim. If
the Plan Administrator determines that special circumstances require additional
time for processing the claim, the Plan Administrator can extend the response
period by an additional ninety (90) days by notifying the claimant in writing,
prior to the end of the initial ninety (90) day period, that an additional
period is required. The notice of extension must set forth the special
circumstances and the date by which the Plan Administrator expects to render its
decision.

 

  7.1.3 Notice of Decision. If the Plan Administrator denies part or all of the
claim, the Plan Administrator shall notify the claimant in writing of such
denial. The Plan Administrator shall write the notification in a manner
calculated to be understood by the claimant. The notification shall set forth:

 

  (a) The specific reasons for the denial;

 

  (b) A reference to the specific provisions of this Agreement on which the
denial is based;

 

  (c) A description of any additional information or material necessary for the
claimant to perfect the claim and an explanation of why it is needed; and

 

  (d) An explanation of this Agreement’s review procedures and the time limits
applicable to such procedures.

 

7.2 Review Procedure. If the Plan Administrator denies part or all of the claim,
the claimant shall have the opportunity for a full and fair review by the Plan
Administrator of the denial as follows:

 

  7.2.1 Initiation – Written Request. To initiate the review, the claimant,
within sixty (60) days after receiving the Plan Administrator’s notice of
denial, must file with the Plan Administrator a written request for review.

 

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Ameriana Bank, SB

Supplemental Retirement Plan

 

 

  7.2.2 Additional Submissions – Information Access. The claimant shall then
have the opportunity to submit written comments, documents, records and other
information relating to the claim. The Plan Administrator shall also provide the
claimant, upon request and free of charge, reasonable access to, and copies of,
all documents, records and other information relevant (as defined in applicable
ERISA regulations) to the claimant’s claim for benefits.

 

  7.2.3 Considerations on Review. In considering the review, the Plan
Administrator shall take into account all materials and information the claimant
submits relating to the claim, without regard to whether such information was
submitted or considered in the initial benefit determination.

 

  7.2.4 Timing of Plan Administrator Response. The Plan Administrator shall
respond in writing to such claimant within sixty (60) days after receiving the
request for review. If the Plan Administrator determines that special
circumstances require additional time for processing the claim, the Plan
Administrator can extend the response period by an additional sixty (60) days by
notifying the claimant in writing, prior to the end of the initial sixty
(60) day period, that an additional period is required. The notice of extension
must set forth the special circumstances and the date by which the Plan
Administrator expects to render its decision.

 

  7.2.5 Notice of Decision. The Plan Administrator shall notify the claimant in
writing of its decision on review. The Plan Administrator shall write the
notification in a manner calculated to be understood by the claimant. If the
claim is denied then the notification shall set forth:

 

  (a) The specific reasons for the denial;

 

  (b) A reference to the specific provisions of this Agreement on which the
denial is based; and

 

  (c) A statement that the claimant is entitled to receive, upon request and
free of charge, reasonable access to, and copies of, all documents, records and
other information relevant (as defined in applicable ERISA regulations) to the
claimant’s claim for benefits.

Article 8

Amendments and Termination

 

8.1 Amendments. This Agreement may be amended only by a written agreement signed
by the Bank and the Director. However, the Bank may unilaterally amend this
Agreement to conform with written directives to the Bank from its auditors or
banking regulators or to comply with legislative changes or tax law, including
without limitation Code Section 409A.

 

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Ameriana Bank, SB

Supplemental Retirement Plan

 

 

8.2 Plan Termination Generally. This Agreement may be terminated only by a
written agreement signed by the Bank and the Director. The benefit shall be the
Account Value as of the date this Agreement is terminated. Except as provided in
Section 8.3, the termination of this Agreement shall not cause a distribution of
benefits under this Agreement. Rather, upon such termination benefit
distributions will be made at the earliest distribution event permitted under
Article 2 or Article 3.

 

8.3 Plan Terminations Under Code Section 409A. Notwithstanding anything to the
contrary in Section 8.2, if the Bank terminates this Agreement in the following
circumstances:

 

  (a) Within thirty (30) days before or twelve (12) months after a Change in
Control, provided that all distributions are made no later than twelve
(12) months following such termination of this Agreement and further provided
that all the Bank’s arrangements which are substantially similar to this
Agreement are terminated so the Director and all participants in the similar
arrangements are required to receive all amounts of compensation deferred under
the terminated arrangements within twelve (12) months of such termination;

 

  (b) Upon the Bank’s dissolution or with the approval of a bankruptcy court
provided that the amounts deferred under this Agreement are included in the
Director’s gross income in the latest of (i) the calendar year in which this
Agreement terminates; (ii) the calendar year in which the amount is no longer
subject to a substantial risk of forfeiture; or (iii) the first calendar year in
which the distribution is administratively practical; or

 

  (c) Upon the Bank’s termination of this and all other arrangements that would
be aggregated with this Agreement pursuant to Treasury Regulations
Section 1.409A-1(c) if the Director participated in such arrangements (“Similar
Arrangements”), provided that (i) the termination and liquidation does not occur
proximate to a downturn in the financial health of the Bank, (ii) all
termination distributions are made no earlier than twelve (12) months and no
later than twenty-four (24) months following such termination, and (iii) the
Bank does not adopt any new arrangement that would be a Similar Arrangement for
a minimum of three (3) years following the date the Bank takes all necessary
action to irrevocably terminate and liquidate the Agreement;

the Bank may distribute the Account Value, determined as of the date of the
termination of this Agreement, to the Director in a lump sum subject to the
above terms.

Article 9

Miscellaneous

 

9.1 Binding Effect. This Agreement shall bind the Director and the Bank and
their beneficiaries, survivors, executors, administrators and transferees.

 

9.2 Non-Transferability. Benefits under this Agreement cannot be sold,
transferred, assigned, pledged, attached or encumbered in any manner.

 

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Ameriana Bank, SB

Supplemental Retirement Plan

 

 

9.3 Tax Withholding and Reporting. The Bank shall withhold any taxes that are
required to be withheld, including but not limited to taxes owed under Code
Section 409A from the benefits provided under this Agreement. The Director
acknowledges that the Bank’s sole liability regarding taxes is to forward any
amounts withheld to the appropriate taxing authorities. The Bank shall satisfy
all applicable reporting requirements, including those under Code Section 409A.

 

9.4 Applicable Law. This Agreement and all rights hereunder shall be governed by
the laws of the State of Indiana, except to the extent preempted by the laws of
the United States of America.

 

9.5 Unfunded Arrangement. The Director and the Beneficiary are general unsecured
creditors of the Bank for the distribution of benefits under this Agreement. The
benefits represent the contractual obligation of the bank to distribute such
benefits. The rights to benefits are not subject in any manner to anticipation,
alienation, sale, transfer, assignment, pledge, encumbrance, attachment or
garnishment by creditors. Any insurance on the Director’s life or other informal
funding asset is a general asset of the Bank to which the Director and
Beneficiary have no preferred or secured claim.

 

9.6 Reorganization. The Bank shall not merge or consolidate into or with another
bank, or reorganize, or sell substantially all of its assets to another bank,
firm or person unless such succeeding or continuing bank, firm or person agrees
to assume and discharge the obligations of the Bank under this Agreement. Upon
the occurrence of such an event, the term “Bank” as used in this Agreement shall
be deemed to refer to the successor or survivor entity.

 

9.7 Entire Agreement. No rights are granted to the Director by virtue of this
Agreement other than those specifically set forth herein.

 

9.8 Interpretation. Wherever the fulfillment of the intent and purpose of this
Agreement requires and the context will permit, the use of the masculine gender
includes the feminine and use of the singular includes the plural.

 

9.9 Alternative Action. In the event it shall become impossible for the Bank or
the Plan Administrator to perform any act required by this Agreement due to
regulatory or other constraints, the Bank or Plan Administrator may perform such
alternative act as most nearly carries out the intent and purpose of this
Agreement and is in the best interests of the Bank, provided that such
alternative act does not violate Code Section 409A.

 

9.10 Headings. Article and section headings are for convenient reference only
and shall not control or affect the meaning or construction of any provision
herein.

 

9.11 Validity. If any provision of this Agreement shall be illegal or invalid
for any reason, said illegality or invalidity shall not affect the remaining
parts hereof, but this Agreement shall be construed and enforced as if such
illegal or invalid provision had never been included herein.

 

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Ameriana Bank, SB

Supplemental Retirement Plan

 

 

9.12 Notice. Any notice or filing required or permitted to be given to the Bank
or Plan Administrator under this Agreement shall be sufficient if in writing and
hand-delivered or sent by registered or certified mail to the address below:

 

  

Ameriana Bank

    

2118 Bundy Avenue

    

New Castle, IN 47362

 

Such notice shall be deemed given as of the date of delivery or, if delivery is
made by mail, as of the date shown on the postmark on the receipt for
registration or certification.

Any notice or filing required or permitted to be given to the Director under
this Agreement shall be sufficient if in writing and hand-delivered or sent by
mail to the last known address of the Director.

 

9.13 Deduction Limitation on Benefit Payments. If the Bank reasonably
anticipates that the Bank’s deduction with respect to any distribution under
this Agreement would be limited or eliminated by application of Code
Section 162(m), then to the extent deemed necessary by the Bank to ensure that
the entire amount of any distribution from this Agreement is deductible, the
Bank may delay payment of any amount that would otherwise be distributed under
this Agreement. The delayed amounts shall be distributed to the Director (or the
Beneficiary in the event of the Director’s death) at the earliest date the Bank
reasonably anticipates that the deduction of the payment of the amount will not
be limited or eliminated by application of Code Section 162(m).

 

9.14 Compliance with Section 409A. This Agreement shall be interpreted and
administered consistent with Code Section 409A.

IN WITNESS WHEREOF, the Director and a duly authorized representative of the
Bank have signed this Agreement.

 

DIRECTOR     BANK

/s/ Richard Hennessey

    By:  

/s/ Jerome J. Gassen

Richard Hennessey     Title:  

President & CEO

 

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Supplemental Retirement Plan

 

 

{    } New Designation

{    } Change in Designation

I, Richard Hennessey, designate the following as Beneficiary under this
Agreement:

 

Primary:      

 

                  %

 

                  % Contingent:      

 

                  %

 

                  %

Notes:

 

  •  

Please PRINT CLEARLY or TYPE the names of the beneficiaries.

 

  •  

To name a trust as Beneficiary, please provide the name of the trustee(s) and
the exact name and date of the trust agreement.

 

  •  

To name your estate as Beneficiary, please write “Estate of [your name]”.

 

  •  

Be aware that none of the contingent beneficiaries will receive anything unless
ALL of the primary beneficiaries predecease you.

I understand that I may change these beneficiary designations by delivering a
new written designation to the Plan Administrator, which shall be effective only
upon receipt and acknowledgment by the Plan Administrator prior to my death. I
further understand that the designations will be automatically revoked if the
Beneficiary predeceases me, or, if I have named my spouse as Beneficiary and our
marriage is subsequently dissolved.

 

Name:  

 

      Signature:  

 

    Date:  

 

Received by the Plan Administrator this      day of                     ,
200    

 

By:  

 

Title: