quick Enrollment Form 457 Deferred Compensation Plans

quick Enrollment form
457 Deferred Compensation Plans
Form
A
• Please review the form instructions for important information.
• Carefully complete all sections of this form in blue or black ink.
• Submit the completed form to your employer to enroll in the ICMA-RC 457 deferred compensation plan.
1. Personal Information
Employer Plan Number: 30 ___ ___ ___ ___ Employer Plan Name: ________________________________________________________
Social Security Number (For tax reporting purposes)
Date of Birth Date Employed/Rehired
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___ ___/ ___ ___ / ___ ___ ___ ___
___ ___/ ___ ___ / ___ ___ ___ ___
Name
Month
Day
Year
Month
Day
Rehired?
Year

Check if yes
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Last
First
MI
Street ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
City ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ State ___ ___ Zip ___ ___ ___ ___ ___ - ___ ___ ___ ___
Daytime Phone (___ ___ ___) - ___ ___ ___ - ___ ___ ___ ___
Gender
: Mp
F p
Marital Status: Married p
Evening Phone (___ ___ ___) - ___ ___ ___ - ___ ___ ___ ___
Single p
Email ______________________________________________
2. Investment Selection
By signing this form, you are electing to invest your contributions in the Milestone Fund with the target date closest to the year in which you reach age 60 (or alternate retirement
age selected by your plan). Please note that after your account has been established, you are able to make changes to your investments at any time.
3. contribution election
Specify the total percentage or dollar amounts you wish to contribute each pay period. Contributions will begin as soon as administratively possible following the month in
which this form is signed.
(Select one option only) Pre-tax deferrals of __________% or $_________________________ from my pay each pay period.
p 1% p 3% p 5% p 15%
or
p $20 p $50 p $100
4. beneficiary designation
Please use whole percentages only (e.g., 50%, not 33 1/3%) and be sure the “% of Benefit” column totals 100%. The beneficiary’s relationship to you can be: spouse, nonspouse, trust, or charity.
Primary Beneficiaries:
Name
Date of Birth
Relationship to You Social Security Number
% of Benefit
(For tax reporting purposes)
____________________________________________
_____/_____/________
_____________________
______ - _____ - _________ ________
____________________________________________
_____/_____/________
_____________________
______ - _____ - _________ Contingent Beneficiaries:
Name
________
Total = 100%
Date of Birth
Relationship to You ____________________________________________
_____/_____/________
____________________________________________
_____/_____/________
Social Security Number
% of Benefit
_____________________
______ - _____ - _________ ________
_____________________
______ - _____ - _________ ________
Total = 100%
(For tax reporting purposes)
If you wish to designate more than two (2) primary and/or contingent beneficiaries, write “see attached” in this section and attach a separate document with the additional
beneficiary(ies) information. The document should also include your Social Security Number, printed name, signature and date.
5. signatures
Sign, date, and submit the completed form to your employer.
__________________________________________________________
Employee Signature __________________________________________________________
______________________________
__________________________________________________________
______________________________
Authorized Employer Official’s Signature
Authorized Employer Official’s Name (Please print)
Date
______________________________
Date
Authorized Employer Official’s Title
ICMA-RC • Attn: Workflow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • En Español 800-669-8216 • www.icmarc.org • Fax 202-682-6439
1st Copy - ICMA-RC
2nd Copy - Employer
FRM000-079-201112-C1287
quick Enrollment Form - 457 Deferred Compensation Plans Instructions
Please review the information you have received from ICMA-RC
carefully prior to enrolling in the plan. The information is intended
to assist you with understanding how the plan works and how it
can help you save for a secure retirement.
Please carefully complete all sections of the form and submit the
completed form to your employer.
Section 1: Personal Information – Provide all of the requested information. The employer plan number can be obtained by
contacting your employer or calling ICMA-RC at 800-669-7400.
Section 2: Investment Selection – Prior to completing this
form, please read Making Sound Investment Decisions: A Retirement Investment Guide and the appropriate prospectus for a full
description of the Milestone Funds. By completing this form, you
are electing to invest your contributions in the Milestone Fund with
the target date closest to the year in which you reach age 60 (or
alternate retirement age selected by your plan). If your enrollment
form does not contain a valid date of birth, your contributions will
be directed to the most conservative target-date fund available.
Section 3: Contribution Election – Use this section to specify
the percentage and/or dollar amounts you will contribute to the
plan. You can change your contribution amount at any time. Your
initial contribution election, and any future changes, will be effective as of the first pay period of the calendar month following the
date you submit the completed form to your employer. For information on the maximum contribution amounts, please go to www.
icmarc.org.
Roth Contributions – If offered by your plan, you can elect to make
Roth contributions in addition to, or instead of, pre-tax contributions. Please check with your employer or ICMA-RC to confirm
availability. To make Roth contributions, you must complete the
457 Deferred Compensation Plan Employee Enrollment Form or
the Amount of Deferral Change Form instead of this form. To learn
more, visit www.icmarc.org/rothanalyzer.
Section 4: Beneficiary Designation – In the event of your
death, your designated beneficiary(ies) will be entitled to any
assets remaining in your account. If no beneficiary information is
provided, your estate will be your beneficiary.
Please provide all of the requested information for each designated beneficiary, including the date of birth and Social Security
number, as this information will help ICMA-RC locate your beneficiaries.
Married Participants Living in Community Property States: Your
spouse is generally entitled to be the primary beneficiary for
100% of your account balance unless he/she waives that right. If
you choose to name someone other than your spouse as primary
beneficiary for your account, please contact ICMA-RC to obtain
the required Community Property Spousal Waiver Form.
Section 5: Signatures – Please be sure to sign and date this
section of the form. Return the completed form to your employer.
Submit the completed form to your employer. Please
do not delay in submitting the completed enrollment form to your
employer. If ICMA-RC receives a contribution to your account prior
to your account being established, the contribution will be returned
to your employer.
WELCOME TO ICMA-RC!
ICMA-RC will send you confirmation of your enrollment. Please
review the confirmation notice and quarterly statements for your
account to ensure your account information is accurate, and
promptly notify ICMA-RC of any updates that are needed.