Form 457 - Deferred Compensation Plan Employee Enrollment Form

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B
457
457 defeRRed CoMpensAtIon pLAn eMpLoYee enRoLLMent foRM - pAge 1 of 2
Complete this form to open an account with ICMA-RC by carefully reading the attached instructions and printing legibly in blue or black ink.
1. requireD PersoNal iNForMatioN
employer Plan Number
employer Plan Name
state
3 0
____ ____ ____ ____
____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
____ ____
Date of Birth
Date employed/rehired
rehire?
social security Number (for tax-reporting purposes)
❐
_____ ____ ____ - ____ ____ - ____ ____ ____ ____
_____ ____ / ____ ____ / ____ ____ ____ ____
_____ ____ / ____ ____ / ____ ____ ____ ____
Month
day
Year
Month
day
Year
check if yes
Full Name of Participant
____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
Last
first
M.I.
Mailing address/street
____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
city
state
Zip code
____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
____ ____
____ ____ ____ ____ ____
Job title:
__________________________________________________________
email address:
_________________________________________________________
gender
Marital status
Daytime Phone Number
evening Phone Number
❐ ❐
❐
❐
_____ ____ ____ / ____ ____ ____ / ____ ____ ____ ____
_____ ____ ____ / ____ ____ ____ / ____ ____ ____ ____
Married
single
M
f
Area Code
Area Code
2. coNtriButioN aMouNt
specify the total percentage and/or dollar amounts you wish to contribute each pay period. Contributions will begin as soon as administratively possible following the month in which this form is signed.
❐
Pre-tax deferrals of __________% or $_________________________ from my pay each pay period.
❐
Roth* deferrals of __________% or $________________________ from my pay each pay period.
*NOT available in all plans. Please check with your employer to confirm that Roth deferrals are offered in your plan before selecting this option.
3. BeNeFiciary DesigNatioN
Please use whole percentages (e.g., 50%, not 33
/
%) and be sure the percentages total 100% when designating primary and contingent beneficiaries.
1
3
Primary Beneficiary(ies):
NaMe
Date oF Birth
relatioNshiP to you*
social security NuMBer
% oF BeNeFit
(for tax-reporting purposes)
(whole %)
_____________________________________________
______/______/________ ______________________
________ - _______ - __________
__________
_____________________________________________
______/______/________ ______________________
________ - _______ - __________
__________
_____________________________________________
______/______/________ ______________________
________ - _______ - __________
__________
total = 100%
contingent Beneficiary(ies), if any:
_____________________________________________
______/______/________ ______________________
________ - _______ - __________
__________
_____________________________________________
______/______/________ ______________________
________ - _______ - __________
__________
_____________________________________________
______/______/________ ______________________
________ - _______ - __________
__________
total = 100%
*the beneficiary relationship options are spouse, non-spouse, trust, estate, and charity.
ICMA-RC • Attn: Workflow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • En Español 800-669-8216 • • Fax 202-682-6439
Ist Copy - ICMA-RC Copy
2nd Copy - employer Copy
FRM570-004- 1211-5369-01

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