Eligible Not Participating Form Page 2

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03/17

( F O R P L A N A D M I N I S T R A T O R ’ S U S E O N L Y )

ELIGIBLE NOT PARTICIPATING FORM

ABA Retirement Funds Program (“the Program”)

Plan Administrator Line: 800.752.6313

P.O. Box 5142 • Boston, MA 02206-5142

Website:

Complete this form to register a non-participating eligible employee in your plan. In the event that the employee wishes to begin contributing,

or the Employer will be making a contribution, please submit an Enrollment Form at that time.

1. EMPLOYER INFORMATION

Program Plan Number: ___ ___ ___ ___ ___ ___ Employer Tax ID Number: ___ ___ – ___ ___ ___ ___ ___ ___ ___ IRS Plan Number: ___ ___ ___

Employer’s Name: ______________________________________________ Employer’s Business Phone Number: (

)

–

2. PARTICIPANT INFORMATION

Participant’s Name: ______________________________________________ Social Security Number: ___ ___ ___–___ ___–___ ___ ___ ___

Sex: c M

c F

Marital Status: c Single c Married

Date of Birth: ___ ___ /___ ___ /___ ___ ___ ___

Participant is an Attorney: c Yes

c No

Participant’s Primary Residence:

Street Address: __________________________________________________________________________________________________________

(MAXIMUM OF 30

____________________________________________________________________________________________________

CHARACTERS EACH LINE)

City:______________________________________________________ State: ________________________ Zip Code: __________________

3. ENROLLMENT INFORMATION

Date of Hire: ___ ___ /___ ___ /___ ___ ___ ___

Entry Date into Plan: ___ ___ /___ ___ /___ ___ ___ ___

4. SIGNATURE

As an Authorized Plan Representative I authorize the enrollment of the above mentioned participant into the plan as eligible and

non-participating. If contributions are made to the participant’s account at a later date, the participant will complete an Enrollment Form.

SIGNATURE OF AUTHORIZED PLAN REPRESENTATIVE ON BEHALF OF THE EMPLOYER

DATE

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