ICMA Enrollment Form

457 DEFERRED COMPENSATION PLAN EMPLOYEE ENROLLMENT FORM
• Use this form to open an account with ICMA-RC. Read instructions on the back before completing this form. Please print legibly in blue or black ink.
• To make legal changes (i.e., change of name, marital status, or beneficiary changes) use the Employee Information Change Form.
• Return this form to your employer promptly. Your employer must provide this form to ICMA-RC before the payroll date of your first deferral. To make address changes,
investment allocation changes or fund transfers, please visit Account Access (www.icmarc.org) or use VantageLine (1-800-669-7400).
1
Required
Participant
Information
Information in
this box must be
completed to
avoid processing
delays.
Employer Plan Number
Employer Plan Name
State
____________________
______________________________________________________________________________
_____
Social Security Number
________ - _______ - ___________
Full Name of Participant
_____________________________________________________
_______________________________________________
Last
First
___
M.I.
Mailing Address/Street
______________________________________________________________________________________________________
City
State
Zip Code
____________________________________________________________________
_____
______________________
Date Employed/Rehired
Date of Birth
______ / ______ / ____________
Month
Day
Month
Day
Year
Email Address
Job Title: ___________________________________________________________________
Area Code
Area Code
Beneficiary
Designation
Gender
(___________) - _________ - ______________
(___________) - _________ - ______________
Name
____________________________________________________
Evening Phone Number
Daytime Phone Number
2
c Check if yes
Rehired?
______ / ______ / ____________
Year
Date of Birth
Primary Beneficiaries:
Relationship to you
Marital Status
c
c
c
M
F
Married
Social Security Number
c
Single
% of benefit
❐ Spouse ❐ Other: __________________
❐ Spouse ❐ Other: __________________
❐ Spouse ❐ Other: __________________
Total = 100%
Contingent Beneficiaries, if any:
❐
❐
❐
Spouse
Spouse
Spouse
❐
❐
❐
Other: __________________
Other: __________________
Other: __________________
Total = 100%
3
Amount of
Deferral
I authorize my employer to defer ____________% or $ ____________________________ from my pay each pay period to be contributed to
my ICMA-RC account, starting on _________ / _______ / _____________ (effective date).
Please indicate which type(s) of deferrals are included in the above amount:
❐
❐
Normal deferral
Catch-up contributions: Please indicate ONE of the following types of catch-up rules you are using:
❐
4
Allocation of
Contributions
“pre-retirement” provision
❐
OR
Fill in the boxes at right with codes of the
fund(s) you want to invest in. A list of funds and
codes can be found on the Investment Options
sheet. See Instruction 4 on the back of this form.
State law, local law, or your employer may place
restrictions on investment in these funds.
“age 50” provision
Note: Please
make sure
percent amounts
total 100%. Use
whole
percentages.
Code
ALLOCATION
Code
Percent
Percent
TOTAL = 100%
5
I acknowledge that I have read and agree to the disclosure (see 5 & 6 on the back of this form).
Employee
Signature
______________________________________________________
______________________
Participant Signature
Date
Employee ID _____________________________
(for Employer Use Only)
6
Employer’s
______________________________________________________________
Authorization Authorized Employer Official’s Signature
_________________________
Date
ICMA-RC • Attn. Records Management Unit • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 1-800-669-7400 • En Español 1-800-669-8216 • www.icmarc.org • Fax 202-682-6439
FRM570-004-200604-01
457 DEFERRED COMPENSATION PLAN EMPLOYEE ENROLLMENT FORM INSTRUCTIONS
Before you complete this form, please read the accompanying
literature so you understand the plan’s provisions. To make
future changes to your account such as address and/or fund
transfers, please use Account Access (www.icmarc.org) or
VantageLine (1-800-669-7400).
IMPORTANT NOTE: Please do not delay in submitting this form.
If we do not have your form by the time we receive your first
deferral, we will be unable to invest your retirement plan assets,
and they will be returned to your employer.
You will receive a confirmation of your enrollment. You will also
receive a quarterly financial statement. Please review these
carefully.
1. PARTICIPANT INFORMATION
Please complete this section carefully. The employer plan number
is available from your employer or ICMA-RC Investor Services at
1-800-669-7400.
2. BENEFICIARY DESIGNATION
Print beneficiaries’ names and Social Security Numbers and
designate their relationship to you and the percentage to be
received. The IRS has certain rules governing disbursement of
funds to beneficiaries. These rules are outlined in your employer’s
plan and in ICMA-RC’s Participant and Beneficiary Withdrawal
Packets.
If none of your primary beneficiaries are living upon your death,
your assets will be distributed to your estate unless you have
designated a contingent beneficiary.
Note: If a Social Security Number is not provided for beneficiaries, and/or ICMA-RC cannot locate the named beneficiaries, the
account balance will be paid to your estate.
SPECIAL CERTIFICATION FOR PARTICIPANTS IN COMMUNITY
PROPERTY STATES
If you are married and live in a Community Property state, you
must generally name your spouse as your beneficiary, unless
your spouse waives this right. ICMA-RC cannot be responsible for
an employee's failure to properly designate a beneficiary in
accordance with state law requirements and the employee’s
failure to provide the certification required by this enrollment
process. Please be advised that failure to meet state law requirements with respect to your beneficiary designation may result in
your beneficiary designation being invalid, and the payment of
benefits to someone other than your designated beneficiary. If
you choose to name a beneficiary that is not your spouse, you
and your spouse will need to complete the Community Property
Spousal Waiver form. Contact 1-800-669-7400 for more information and to request the waiver form.
3. AMOUNT OF DEFERRAL
IRS regulations allow you to defer the lesser of (1) the full 100% of
your gross income after subtracting any Section 414(h) picked-up
contributions (mandatory employee contributions to 401 qualified
retirement plans made with pre-tax dollars), or (2) a dollar limit in
effect for that year. If you are age 50 or older, you may make
additional annual catch-up contributions of a dollar limit in effect
for that year. In addition, there are special catch-up provisions
during the three years prior to the calendar year of normal
retirement age. For the applicable dollar limits, please log on to
www.icmarc.org or contact Investor Services at 1-800-669-7400. A
participant may increase, decrease, and/or start, stop and restart
contributions by executing appropriate forms and will be effective,
if practical, the first pay period of the calendar month
commencing after the date the amendment is executed. If you
defer more than allowed under IRS regulations, it is your
responsibility to correct the error.
4. ALLOCATION OF CONTRIBUTIONS
You may place your contributions in one fund or in any combination of funds, although your employer may place restrictions on
investment in certain funds. If the allocation total does not add
up to 100 percent then the remainder will be allocated to the PLUS
Fund. If no selection is given, your contribution will be allocated
to the default fund selected by your employer. Use whole percentages (e.g., 50 percent, not 33 1/3 percent). Do not use fixed dollar
amounts. Please see the VantageTrust Company’s Making Sound
Investment Decisions: A Retirement Investment Guide and the
appropriate prospectus for full descriptions of the funds.
PLEASE NOTE: This will affect contributions only. To specify the
allocation for your rollover contributions, please complete a
Trustee-to-Trustee Transfer to ICMA-RC form.
5 & 6. AUTHORIZED SIGNATURES
Once you have completed this form, sign it and submit it to your
employer for approval.
Note that by signing this form you acknowledge that you agree to
the following:
I have received and read the current VantageTrust Company’s
Making Sound Investment Decisions: A Retirement Investment
Guide and the appropriate prospectus. I understand that ICMA-RC
has established required procedures for Internet and telephone
transfers that include personal identification numbers, recording
of instructions, and written confirmations. In the event I choose to
transfer funds by Internet or telephone, I agree that neither the
VantageTrust Company, ICMA-RC, ICMA-RC Services, LLC, nor
Vantagepoint Transfer Agents, LLC, will be liable for any loss, cost,
or expense for acting upon any Internet or telephone instructions
believed by it to be genuine and in accordance with the required
procedures.
An authorizing signature does not represent an obligation to use
the telephone transfer feature available on VantageLine.
Welcome to ICMA-RC!