Please check one:
I am eligible for the employer contribution.
I am not eligible for the employer contribution.
NOTE: APA match of up to 4% of base salary beginning the first full pay period after the employee’s first year anniversary. APA’s
contribution will not exceed 4% of an employee’s base salary.
I, _________________________________(employee) hereby elect to have my basic annual salary reduced by the
amount indicated below and to have that amount contributed to the APA 401(k) Plan. (Salary refers to basic annual salary and
does not include bonus, overtime, or any supplemental pay, but does include salary deferrals under IRS Sections 125 and
401(k).) I understand that this election will be effective as of _________________, 20__ (not earlier than the pay period
beginning on or after the date of this election).
I understand that I may change or terminate this Agreement as of the end of any quarter with respect to salary earned
after the date of such change or termination, by filing a new election or revocation form.
Complete the appropriate section:
I elect to contribute _____________% (any percentage) of my base salary, up to the limits set by the Plan or by law. I
understand that the amount I contribute may not exceed the maximum amount permitted by law unless I am eligible for
and elect to make the additional “catch up contribution” described below. In addition, I understand that if I am considered
“highly compensated” (as defined in the Plan), the amount I may contribute may be limited by certain tests that apply under
Section 401(k) of the Internal Revenue Code.
Catch-Up Contribution (Employees age 50 and older). If you are age 50 or older, you may elect to contribute an
additional $_______________ in addition to any other limits that apply under the Plan. If you elect to make a catchup contribution, your salary reduction election will continue to apply until you have contributed the maximum
permitted by law for individuals age 50 or older.
I elect to make the additional $______________ catch-up contribution.
I have been informed of my eligibility to participate in the plan and I choose NOT to participate at this time. I
understand that I may change this election and enroll as of the beginning of any future pay period.
I understand that the amount defined above will be paid to the fund(s) designated on the Retirement Plan Enrollment Form.
Human Resources Representative
Human Resources Use ONLY
APA Matching Contribution up to a Maximum of 4%: ______
DC1 30066993v1
Revised 3/11/09