Employee name __________________________ Social Security # __________________
Home address ___________________________________________________________
Phone # ________________________________________________________________
ACTION REQUESTED
| ( ) Enroll | ( ) Re-enroll |
| ( ) Stop deductions | ( ) Change contribution amount |
| ( ) Terminate participation | . |
TAX-DEFERRED CONTRIBUTIONS
I agree to contribute _____% or $__________, per pay period effective the first payroll of the following month, not to exceed applicable IRS dollar limits for the calendar year.
CATCH UP CONTRIBUTIONS (available for employees age 50 or older by the end of the calendar year)
I agree to contribute an additional catch-up contribution of $_____________ per pay period, not to exceed applicable IRS dollar limits for the calendar year.
I understand that I may change, suspend and resume contributions at such times as described in the terms of the plan and that my salary reduction participation is completely voluntary.
I agree to be bound by the terms of the plan and acknowledge that I have received the summary plan description and have completed a designation of beneficiary form.
_____________________________________ ________________________
Employee signature Date
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