Form Orp-Enroll - Retirement Plan Enrollment Form

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ORP-ENROLL

Florida Retirement System (FRS)

*EY*

12/13

State University System Optional Retirement Program (SUSORP)

Retirement Plan Enrollment

Enrollment

PO Box 9000, Tallahassee, FL 32315-9000

Toll Free: 877-377-3675

Local: 850-488-8837

Fax: 850-410-2196

SECTION I

Name

_____________________________________

____________________________

___________

(Last name)

(First name)

(Middle initial)

Social Security Number: ___________________ Birth Date: ____________Gender: Male ___ Female ____

mm/dd/yyyy

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SECTION II

I WANT TO BE AN FRS MEMBER

___

I am a new member and will complete the

___

I am an existing FRS member and want

Form ELE-1 or Form ELE-1-EZ as appropriate.

to retain my participation in the FRS.

Proceed To Section IV – Signature

Proceed To Section IV - Signature

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SECTION III

I WANT TO BE A SUSORP MEMBER

___

I am a new member and wish to enroll

___

I am an existing SUSORP member and want to

in the SUSORP.

retain my participation in the SUSORP.

As a SUSORP member, I understand that:

It is my responsibility to ensure that my tax-deferred income deductions do not exceed the maximum amount set in the Internal

Revenue Service Code and Regulations.

I may choose to have up to 5.14% of my adjusted gross taxable salary deducted as my Voluntary Employee Contribution;

however, (a) I must be under the maximum exclusion allowance and (b) my adjusted gross income minus any payroll deductions

(e.g., credit union, or 457 plan), must be sufficient to cover the Voluntary Employee Contribution.

I elect the following:

Required Employer and Employee Contributions

Voluntary Employee Contribution

The total employer contribution is 5.14%. I choose to allocate

Provider Company

contributions to one or more provider companies as indicated

(Total percentage must not

below. My 3% required employee contribution will also be

exceed 5.14% of your salary)

allocated at the same ratio.

MetLife Investors

TIAA-CREF

VALIC

Jefferson National

ING

0.00

Total

___________

Total

___________

(Must equal 5.14%)

(Must not exceed 5.14%)

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

SECTION IV

SIGNATURE

Member Signature: ____________________________________

Date: ________________________

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

SECTION V

TO BE COMPLETED BY EMPLOYER:

Agency Name: ________________________________________________ Agency Number: ______________

Class Code: _____________ Position Number: ______________

Position Title: _____________________________________________________________________________

Date of Employment in SUSORP Eligible Position: __________________ Effective Date: _________________

I certify that the above information is correct and this member is employed in a SUSORP-eligible position and has executed a

contract(s) with the SUSORP provider(s) elected above.

________________________________________

________________

Authorized Personnel Signature

Date