Simple Ira Salary Deferral Election

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Salary Deferral Election
For employer/employee use only
Important information
If you are opening a new account, you must attach a completed SIMPLE IRA Application to this form. Your employer will forward the
completed application to American Funds Service Company
on your behalf.
Return this completed form to your employer. Do not send this form to American Funds Service Company or Capital Bank and
Trust Company.
General information
Please type or print clearly.
Name of employee
Name of employer
Payroll election
See the chart at the bottom of this page for deferral and catch-up limits. Select one of the following five options.
New election for NEW accounts — I am opening a new account ( the application is attached ) and elect to participate in the
SIMPLE IRA Plan. ( Specify your election and effective date below. )
Pre-tax deferrals of
Effective date
( mm/dd/yyyy )
Change deferrals — I am currently participating in a SIMPLE IRA Plan and wish to change my election. ( Specify your election
and effective date below. )
Pre-tax deferrals of
Effective date
( mm/dd/yyyy )
Maintain deferrals — I am participating in a SIMPLE IRA plan and wish to maintain my current deferral election.
Suspend deferrals — I wish to stop participating in the SIMPLE IRA Plan as of the effective date specified below.
Effective date
( mm/dd/yyyy )
I do not wish to participate in the SIMPLE IRA Plan at this time.
If electing salary deferrals, I authorize my employer to withhold the amount/percentage specified above from each paycheck as of the effective
date provided, which will reduce my compensation under this election ( my elective deferral contributions ) . I may revoke or update this election
at any time as permitted by my employer. My elective deferral contributions are not subject to federal ( or state, if applicable ) income tax until
distributed from the Plan. If I revoke this election, I acknowledge that, contingent upon the terms of the SIMPLE IRA Plan, I may be prohibited
from submitting another Salary Deferral Election until the enrollment period immediately preceding the next plan year. The revocation or update
will be effective as soon as administratively possible by my employer after they have received the notice. I also understand that my elective
deferral contributions are subject to gain or loss in accordance with my selected investments.
Date ( mm/dd/yyyy )
Signature of employee
Deferral limit
Catch-up limit*
You must be at least 50 years old to make a catch-up contribution.


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