Form Orp-Change - Change Form Florida
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1*EP*
ORP-CHANGE
Florida Retirement System
12/13
State University System Optional Retirement Program (SUSORP)
Enrollment
Change Form
PO Box 9000, Tallahassee, FL 32315-9000
Toll Free: 877-377-3675
Local: 850-488-8837
Fax: 850-410-2196
Name
_____________________________________
____________________________
___________
:
(Last name)
(First name)
(Middle initial)
Social Security Number: ___________________ Birth Date: ____________Gender: Male ___ Female ____
mm/dd/yyyy
As a participating SUSORP member, I elect the following changes:
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
0.00
Total
___________
Total
___________
(Must equal 5.14%)
(Must not exceed 5.14%)
I understand that:
1.
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.
2.
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.
Member Signature: ____________________________________
Date: ________________________
TO BE COMPLETED BY EMPLOYER:
Agency Name: _____________________________________________ Agency Number: _______________
Member’s Reason for Submitting this Form:
Company Change
Contributions Change
Effective pay date for change _________________
________________________________________
________________
Authorized Personnel Signature
Date
Rule 60U‐2.003, F.A.C.
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