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401(k) Election Form
Salary Deferral Election (with ROTH Deferral Option)
Plan Name:
Election Type:
Initial Enrollment
Change of Prior Election
One-time Bonus Election
Cancellation
PERSONAL INFORMATION
Last Name
SS#:
:
First Name:
Date of Birth:
Date of Hire:
Address:
City:
State:
Zip:
Phone:
Email:
Effective Date of Election:
SALARY REDUCTION ELECTION
Subject to the requirements and limitation of the Plan, I elect to defer the following amount of my eligible compensation (i.e. wages, salary, etc.) in to the Plan
each pay period.
I elect not to contribute at this time
% or
$
or
Max (
) into my Pre-Tax 401(k) Account per pay
limited to IRS annual limit
% or
$
or
Max (
) into my ROTH Account per pay period
limited to IRS annual limit
CATCH-UP CONTRIBUTION
(FOR PARTICIPANTS WHO ARE AGE 50 OR OLDER)
The catch-up contribution is only available if you are at least age 50 at any time during the calendar year during which you are making deferrals.
By making a catch-up election here, you are certifying that you are eligible to do so.
I elect the maximum catch-up contribution into my:
Pre-Tax 401(k)
ROTH
ROTH $
I elect the following catch-up contribution into my:
Pre-Tax 401(k) $
CHANGES TO DEFERRAL AMOUNT
The Employer agrees to contribute the amount designated above as salary deferrals into the appropriate accounts under the
Plan. I understand that I may change or cancel my election by completing a new Election Form as authorized under the Plan's
Deferral election procedures. I understand that my election will be processed as soon as administratively feasible.
(Questions regarding ability to change or cancel an existing salary reduction election should be directed to the HR/Payroll
Department)
REQUIRED SIGNATURES
Participant Authorization
Acceptance of Salary Deferral Election Form
I understand that my elected deferrals will be withheld from each pay
check and forwarded to the investment company per my investment
election form. I further understand that I should complete a Beneficiary
Designation Form available from HR/Payroll Department, or at
Participant Signature
Date
Employer Signature
Date
1
