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!
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