Pollert Retirement Agreement


    


    EXHIBIT
      10.5

    


    HOMEFEDERAL
      BANK

    Supplemental
      Executive Retirement Agreement

    


    HOMEFEDERAL
      BANK

    SUPPLEMENTAL
      EXECUTIVE RETIREMENT AGREEMENT

    


    


    THIS
      SUPPLEMENTAL EXECUTIVE RETIREMENT AGREEMENT (the “Agreement”) is adopted this
      ________ day of _______________, 2005, by and between HOMEFEDERAL BANK, an
      Indiana-chartered commercial
      bank located in Columbus, Indiana (“Bank”) and
      Elaine Pollert (the “Executive”). The purpose of this Agreement is to provide
      specified benefits to the Executive, a member of a
      select
      group of management or highly compensated employees who contribute materially
      to
      the continued growth, development, and future business success of the
Bank.
      This Agreement shall be unfunded for tax purposes and for purposes of Title
      I of
      the Employee Retirement Income Security Act of 1974 (“ERISA”), as amended from
      time to time. 

    


    Article
      1

    Definitions

    


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

    


    
      	1.1  	
              “Beneficiary”
                means each designated person, or the estate of the deceased Executive,
                entitled to benefits, if any, upon the death of the Executive determined
                pursuant to Article 4.

            


    

    


    
      	1.2  	
              “Beneficiary
                Designation Form”
                means the form established from time to time by the Plan Administrator
                that the Executive completes, signs, and returns to the Plan Administrator
                to designate one or more
                Beneficiaries.

            


    

    


    
      	1.3  	
              “Board”
                means the Board of Directors of the Bank as from time to time
                constituted.

            


    

    


    
      	1.4  	
              “Code”
                means the Internal Revenue Code of 1986, as
                amended.

            


    

    


    
      	1.5  	
              “Disability”
                means Executive (i) is unable to engage in any substantial gainful
                activity by reason of any medically determinable physical or mental
                impairment which can be expected to result in death or can be expected
                to
                last for a continuous period of not less than 12 months, or (ii)
                is, by
                reason of any medically determinable physical or mental impairment
                which
                can be expected to result in death or can be expected to last for
                a
                continuous period of not less than 12 months, receiving income replacement
                benefits for a period of not less than 3 months under an accident
                and
                health plan covering employees of the Executive’s employer. Medical
                determination of Disability may be made by either the Social Security
                Administration or by the provider of an accident or health plan covering
                employees of the Executive’s employer. Upon the request of the Plan
                Administrator, the Executive must submit proof to the Plan Administrator
                of Social Security Administration’s or the provider’s
                determination.

            


    

    


    
      	1.6  	
              “Effective
                Date”
                means July 1, 2005.

            


    


    
      
        
        

      

      
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    HOMEFEDERAL
      BANK

    Supplemental
      Executive Retirement Agreement

    


    
      	1.7  	
              “Plan
                Administrator”
                means the plan administrator described in Article
                6.

            


    

    


    
      	1.8  	
              “Plan
                Year”
                means each twelve-month period commencing on July 1 and ending on
                June 30
                of each year. The initial Plan Year shall commence on the Effective
                Date
                of this Agreement and end on the following June 30,
                2006.

            


    

    


    
      	1.9  	
              “Separation
                from Service”
                means
                that the Executive’s service, as an employee and independent contractor,
                to the Bank and any member of a controlled group as defined in Section
                414
                of the Code to which the Bank belongs, has terminated for any reason,
                other than by reason of a leave of absence approved by the Bank or
                the
                death of the Executive.

            


    

    


    
      	1.10  	
              “Termination
                for Cause”
                has that meaning set forth in Article
                5.

            


    

    


    Article
      2

    Distributions
      During Lifetime

    


    
      	
              2.1

            	
              Retirement
                Benefit.
                At the date specified in Section 2.1.2, the Bank shall distribute
                to the
                Executive 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 Five Thousand Three
                Hundred
                Thirty-Six Dollars ($5,336). 

            


    

    


    
      	 	
              2.1.2

            	
              Distribution
                of Benefit.
                The Bank shall distribute the annual benefit to the Executive in
                twelve
                (12) equal monthly installments commencing on the first day of the
                month
                following the later of: (a) Separation from Service or (b) the date
                the
                Executive reaches age 50. The annual benefit shall be distributed
                to the
                Executive for fifteen (15) years.

            


    

    


    
      	
              2.2

            	
              Disability
                Benefit.
                If
                the Executive’s Disability results in Separation from Service prior to the
                date she reaches age 50, the Bank shall distribute to the Executive
                the
                benefit described in this Section 2.2 in lieu of any other benefit
                under
                this Article.

            


    

    


    
      	 	
              2.2.1

            	
              Amount
                of Benefit. The
                annual benefit under this Section 2.2 is Five Thousand Three Hundred
                Thirty-Six Dollars ($5,336.00).

            


    

    


    
      	 	
              2.2.2

            	
              Distribution
                of Benefit.
                The Bank shall distribute the annual benefit to the Executive in
                twelve
                (12) equal monthly installments commencing within Sixty (60) days
                following the date the Executive has a Separation from Service due
                to
                Disability. The annual benefit shall be distributed to the Executive
                for
                fifteen (15) years.

            


    

    


    
      	
              2.3

            	
              Restriction
                on Timing of Distribution. 
                Notwithstanding any provision of this Agreement to the contrary,
                if the
                Executive is considered a “specified employee” under Section
                

            


    


    
      
        
        

      

      
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    HOMEFEDERAL
      BANK

    Supplemental
      Executive Retirement Agreement

    


      
      409A of the Code and regulations thereunder, benefit
      distributions that qualify as a "separation from service" under Section 409A
      of
      the Code and regulations thereunder may not commence earlier than six (6) months
      after the date of such separation from service.

    


    Article
      3

    Distribution
      at Death

    


    
      	
              3.1

            	
              Death
                During Active Service.
                If the Executive dies while in the active service to the Bank, the
                Bank
                shall distribute to the Beneficiary the benefit described in this
                Section
                3.1. This benefit shall be distributed in lieu of the benefits under
                Article 2.

            


    

     

    
      	3.1.1  	
              Amount
                of Benefit.
                The
                benefit under this Section 3.1 is the Retirement Benefit described
                in
                section 2.1.1. 

            


    

    


    
      	 	
              3.1.2

            	
              Distribution
                of Benefit.
                The Bank shall distribute the annual benefit to the Executive in
                twelve
                (12) equal monthly installments commencing within
                Sixty (60) days following receipt by the Bank of the Executive's
                death
                certificate and payable
                on the first day of each month that follows.
                The annual benefit shall be distributed to the Executive for fifteen
                (15)
                years.

            


    

    


    
      	
              3.2

            	
              Death
                During Distribution of a Benefit.
                If the Executive 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 Executive
                had
                the Executive survived.

            


    

    


    
      	
              3.3

            	
              Death
                After Separation from Service But Before Benefit Distributions
                Commence. If
                the Executive is entitled to benefit distributions under this Agreement,
                but dies prior to the commencement of said benefit distributions,
                the Bank
                shall distribute to the Beneficiary the same benefits that the Executive
                was entitled to prior to death except that the benefit distributions
                shall
                commence within Sixty (60) days following receipt by the Bank of
                the
                Executive’s death certificate.

            


    

    


    Article
      4

    Beneficiaries

    


    
      	
              4.1

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

            


    

    


    
      	
              4.2

            	
              Beneficiary
                Designation: Change.
                The Executive shall designate a Beneficiary by completing and signing
                the
                Beneficiary Designation Form, and delivering it to the Plan
                

            


    


    
      
        
        

      

      
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    HOMEFEDERAL
      BANK

    Supplemental
      Executive Retirement Agreement

    


      
      Administrator or its designated agent. The Executive's beneficiary designation
      shall be deemed automatically revoked if the Beneficiary predeceases the
      Executive or if the Executive names a spouse as Beneficiary and the marriage
      is
      subsequently dissolved. The Executive 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,
      as in effect from time to time. 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 Executive and accepted by
      the
      Plan Administrator prior to the Executive’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 Executive dies without a valid beneficiary designation, or
                if all
                designated Beneficiaries predecease the Executive, then the Executive’s
                spouse shall be the designated Beneficiary. If the Executive has
                no
                surviving spouse, the benefits shall be made to the personal
                representative of the Executive'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 Executive
                and the
                Executive’s Beneficiary, as the case may be, and shall be a complete
                discharge of any liability under the Agreement for such distribution
                amount.

            


    

    


    Article
      5

    General
      Limitations

    


    
      	5.1
                	
              Termination
                for Cause.
                Notwithstanding any provision of this Agreement to the contrary,
                the Bank
                shall not distribute any benefit under this Agreement if Executive’s
                service is terminated by the Board
                for:

            


    

    


    
      	(a)
                	
              Gross
                negligence or gross neglect of duties to the Bank;
                or

            


    

    
      	(b)
                	
              Conviction
                of a felony or of a gross misdemeanor involving moral turpitude in
                connection with the Executive’s service with the Bank; or
                

            


    

    
      	(c)
                	
              Fraud,
                disloyalty, dishonesty or willful violation of any law or significant
                Bank
                policy committed in connection with the Executive's service and resulting
                in a material adverse effect on the
                Bank.

            


    

    



    
      
        
        

      

      
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    HOMEFEDERAL
      BANK

    Supplemental
      Executive Retirement Agreement

    


    


    
      	
              5.2

            	
              Suicide
                or Misstatement.
                No benefits shall be distributed if the Executive commits suicide
                within
                two years after the Effective Date of this Agreement, or if an insurance
                company which issued a life insurance policy covering the Executive
                and
                owned by the Bank denies coverage (i) for material misstatements
                of fact
                made by the Executive on an application for such life insurance,
                or (ii)
                for any other reason; provided, however that the Bank shall evaluate
                the
                reason for the denial, and upon advice of legal counsel and in its
                sole
                discretion, consider judicially challenging any
                denial.

            


    

    


    
      	5.3  	
              Removal. Notwithstanding
                any provision of this Agreement to the contrary, the Bank shall not
                distribute any benefit under this Agreement if the Executive is subject
                to
                a final removal or prohibition order issued by an appropriate federal
                banking agency pursuant to Section 8(e) of the Federal Deposit Insurance
                Act ("FDIA").

            


    

    


    Article
      6

    Administration
      of Agreement

    


    
      	
              6.1

            	
              Plan
                Administrator Duties.
                This Agreement shall be administered by a Plan Administrator which
                shall
                consist of the Board, or such committee or person(s) as the Board
                shall
                appoint. The Plan Administrator shall also have the discretion and
                authority to (i) make, amend, interpret and enforce all appropriate
                rules
                and regulations for the administra-tion of this Agreement and (ii)
                decide
                or resolve any and all ques-tions including interpretations of this
                Agreement, as may arise in connection with the
                Agreement.

            


    

    


    
      	
              6.2

            	
              Agents.
                In the administration of this Agreement, the Plan Administrator may
                employ
                agents and delegate to them such administrative duties as it 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.
                The decision or action of the Plan Administrator with respect to
                any
                question arising out of or in connection with the administration,
                interpretation and application of the Agreement and the rules and
                regulations promulgated hereunder shall be final and conclusive and
                binding upon all persons having any interest in the Agreement.
                

            


    

    


    
      	
              6.4

            	
              Indemnity
                of Plan Administrator.
                The Bank shall indemnify and hold harmless the members of 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 or any of its
                members.

            


    

    


    
      	
              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 circum-stances of the retirement,
                Disability, death, or Separation from Service of the Executive, and
                such
                other pertinent information as the Plan Administrator may reasonably
                require.

            


    


    
      
        
        

      

      
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    HOMEFEDERAL
      BANK

    Supplemental
      Executive Retirement Agreement

    


    
      	
              6.6

            	
              Annual
                Statement.
                The Plan Administrator shall provide to the Executive, 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.

            


    

    


    Article
      7

    Claims
      and Review Procedures

    


    
      	
              7.1

            	
              Claims
                Procedure.
                An Executive or Beneficiary (“claimant”) who has not received benefits
                under the 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.

            


    

    


    
      	 	
              7.1.2

            	
              Timing
                of Plan Administrator Response.
                The Plan Administrator shall respond to such claimant within 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 90
                days by
                notifying the claimant in writing, prior to the end of the initial
                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 the 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;

            


    

    
      	 	
              (d)

            	
              An
                explanation of the Agreement’s review procedures and the time limits
                applicable to such procedures; and

            


    

    
      	 	
              (e)

            	
              A
                statement of the claimant’s right to bring a civil action under ERISA
                Section 502(a) following an adverse benefit determination on
                review.

            


    

    


    
      	
              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 60 days after receiving
                the
                Plan Administrator’s notice of denial, must file with the Plan
                

            


    


    
      
        
        

      

      
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    HOMEFEDERAL
      BANK

    Supplemental
      Executive Retirement Agreement

    


    


    Administrator
      a written request for review.

    


    
      	 	
              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 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 60 days by notifying the claimant in writing,
                prior to the end of the initial 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. The notification
                shall set forth:

            


    

    


    
      	 	
              (a)

            	
              The
                specific reasons for the denial;

            


    

    
      	 	
              (b)

            	
              A
                reference to the specific provisions of the Agreement on which the
                denial
                is based;

            


    

    
      	 	
              (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;
                and

            


    

    
      	 	
              (d)

            	
              A
                statement of the claimant’s right to bring a civil action under ERISA
                Section 502(a). 

            


    

    


    Article
      8

    Amendments
      and Termination

     

       
      8.1      Amendment. 
      This Agreement may be amended only by a written agreement signed by the Bank
      and
      the Executive; provided, however, that the Bank may amend this Agreement to
      conform with legislative requirements or written directives to the Bank from
      its
      banking regulators. 


    
      
        
        

      

      
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    HOMEFEDERAL
      BANK

    Supplemental
      Executive Retirement Agreement

    


    


       
      8.2       Termination.
      This
      Agreement may be terminated only by a written agreement signed by the Bank
      and
      the Executive.  Upon such termination, the applicable benefits under this
      Agreement shall be paid to the Executive in the form and at the earliest
      possible time as specified in this Agreement and permitted under Section 409A
      of
      the Code and any applicable subsequent authority.

    


    Article
      9

    Miscellaneous

    


    
      	
              9.1

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

            


    

    


    
      	
              9.2

            	
              No
                Guarantee of Employment.
                This Agreement is not a contract for employment. It does not give
                the
                Executive the right to remain as an employee of the Bank, nor does
                it
                interfere with the Bank's right to discharge the Executive. It also
                does
                not require the Executive to remain an employee nor interfere with
                the
                Executive's right to separate from service at any
                time.

            


    

    


    
      	
              9.3

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

            


    

    


    
      	
              9.4

            	
              Tax
                Withholding.
                The Bank shall withhold any taxes that are required to be withheld,
                under
                Section 409A of the Code and regulations thereunder, from the benefits
                provided under this Agreement. The Executive acknowledges that the
                Bank’s
                sole liability regarding taxes is to forward any amounts withheld
                to the
                appropriate taxing authority(ies). 

            


    

    


    
      	
              9.5

            	
              Applicable
                Law.
                The 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.

            


    

    


    
      	
              9.6

            	
              Unfunded
                Arrangement.
                The Executive and Beneficiary are general unsecured creditors of
                the Bank
                for the distribution of benefits under this Agreement. The benefits
                represent the mere promise by 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 Executive's life
                or
                other informal funding asset is a general asset of the Bank to which
                the
                Executive and Beneficiary have no preferred or secured
                claim.

            


    

    


    
      	
              9.7

            	
              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 event, the term “Bank” as used in
                this Agreement shall be deemed to refer to the successor or
                

            


    


    
      
        
        

      

      
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    HOMEFEDERAL
      BANK

    Supplemental
      Executive Retirement Agreement

    


    


    survivor
      bank.

    


    
      	
              9.8

            	
              Entire
                Agreement. This
                Agreement constitutes the entire agreement between the Bank and the
                Executive as to the subject matter hereof. No rights are granted
                to the
                Executive by virtue of this Agreement other than those specifically
                set
                forth herein.

            


    

    


    
      	
              9.9

            	
              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: 

            


    

     

    

      


      HomeFederal
        Bank

      Attn:
        ___________

      501
        Washington Street

      Columbus,
        IN 47201

      
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 Executive under this
      Agreement shall be sufficient if in writing and hand-delivered, or sent by
      mail,
      to the last known address of the Executive.

    


    


    


    


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

    


    
      	
              EXECUTIVE:

            	
              BANK:

            
	 	
              HOMEFEDERAL
                BANK

            
	 	 	 
	 	
              By

            	 
	
              Elaine
                Pollert

            	 	 
	 	
              Title

            	 


    

    



    
      
        
        

      

      
        9

        
          

        

      

      
        
        

      

    


    HOMEFEDERAL
      BANK

    Supplemental
      Executive Retirement Agreement

    BENEFICIARY
      DESIGNATION FORM

    


    I,
      Elaine
      Pollert ,
      designate the following as Beneficiary under the 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 ____________________,
                2____

            
	 	 	 	 
	
              By:

            	 	 	 
	 	 	 	 
	
              Title: