Fillable Salary Reduction Agreement & Beneficiary Designation Form printable pdf download

Adventist Retirement Plan

Salary Reduction Agreement & Beneficiary Designation Form

New Enrollment

Beneficiary Change

Deferral Change

Employee Information

Name: ________________________________________________ SSN: ______________________________

Address: __________________________________________________________________________________

City: ___________________________________ State: ___________________ ZIP: ____________________

Voluntary Contribution

I wish to make employee pre-tax contributions to the Adventist Retirement Plan in the following percentage of my

eligible salary every pay period: ______________________%

I wish to make employee pre-tax contributions to the Adventist Retirement Plan every pay period in the

amount of $ _______________________.

I do not wish to make any voluntary contributions.

Beneficiary Designation

(complete only if you are enrolling in the Plan or changing your beneficiary)

If married, you may only designate your spouse as Primary Beneficiary on this form. To name more than one beneficiary

or to name someone other than your spouse, you must complete an Alternative Beneficiary Designation Form.

Primary Beneficiary

Contingent Beneficiary

Name: __________________________________________

Name: ___________________________________________

SSN: ___________________________________________

SSN: ____________________________________________

Relationship: _____________________________________

Address: ________________________________________

Address: _________________________________________

City: _____________________ State: ________________

City: ________________________ State: ______________

ZIP: __________________ Birth Date: _______________

ZIP: ____________________ Birth Date: ______________

Employee Signature

( must select one below )

I DO NOT WISH to participate in a salary reduction agreement with the Adventist Retirement Plan at this time.

I understand, that by not participating I will be ineligible for the employer matching contribution. I further understand

that I may elect to participate in the Plan in the future, and it is my responsibility to contact the Human Resources

Department through my employer to do so.

I agree that my employer my reduce my salary by the percentage or amount which I have elected to contribute to the

Adventist Retirement Plan, which is a tax-deferred savings plan. I understand that the Adventist Retirement Plan may

limit my contributions in order to comply with federal law and the Plan document.

Attention K-12 Educational Employees!

K-12 educational employees who have 10-month contracts may receive an upward adjustment in remuneration to

Fully compensate them for their estimated employer contribution loss. These employees are urged to contribute this

pay adjustment to their voluntary defined contribution account.

_____________ I am / am not including the special pay increase in the voluntary contribution section above.

(Employee Initial)

( circle one )

Employee Signature

Date

For Processing Please Return This Form to Your Local Payroll Office

Questions about this form may be directed to 1888-568-2542, Monday through Friday, 8:00 a.m. to 6:00 p.m. Eastern Time

Salary Reduction Agreement & Beneficiary Designation Form

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