Paycheck Contribution Election
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1
2Paycheck Contribution Election
401(k) Plan
A
939386-01 Child & Family Services, Inc. 401(k) Plan
B
Participant Information
Use black or blue ink when completing this form. For questions regarding this form, contact Service Provider at 1-800-338-4015.
Social Security Number
Account Extension
/
/
Last Name
First Name
M.I.
Date of Birth
Payroll Election(s)
(
)
Street Address
Personal Phone Number
Paycheck Contribution Election
(
)
City
State
Zip Code
Work Phone Number
Account extension identifies funds transferred to a
beneficiary due to death, alternate payee due to divorce
Married
Unmarried
Email Address
or a participant with multiple accounts.
I have a retirement savings account with a previous employer or an IRA.
Yes or
No
I would like help consolidating my other retirement accounts into my account with Great-West Retirement Services ® .*
Yes, I would like a
representative to call me at phone #
-
-
to review my options and assist me with the process. The best time to
call is
to
A.M./P.M. (circle one - available 8:00 A.M. to 6:00 P.M. MST). *Rollovers are subject to my Plan’s provisions.
(Payroll Deductions)
Age 50 Catch-Up Election
Select One:
Start
Restart
Change
Stop
Decline
I elect to contribute to the Plan the following percentage(s) of my eligible compensation indicated below (per pay period):
Before-Tax Contributions
%
(1% - 100%)
Roth Contributions
%
(1% - 100%)
Payroll Effective Date (mm/dd/yyyy)
/
/
Date of Hire (mm/dd/yyyy)
/
/
The total annual before-tax and Roth contributions cannot exceed $17,000.00 of my eligible compensation in the 2012 tax year.
I elect to contribute to the Plan additional Age 50 Catch-Up percentage(s) of my eligible compensation as indicated below (per pay period):
Before-Tax Contributions
%
Roth Contributions
%
Payroll Effective Date (mm/dd/yyyy)
/
/
The total before-tax and Roth Age 50 Catch-Up amount cannot exceed $5,500.00 of my eligible compensation in the 2012 tax year. I must
be age 50 or older during this calendar year and I must be currently deferring the maximum amount allowable under the Internal Revenue
Code and applicable regulations and/or my Plan. If I stop my deferrals and/or do not defer the maximum amount during this calendar year,
the Age 50 Catch-Up amount I have elected to contribute will not be considered a Catch-Up deferral. The Catch-Up contributions will be
allocated in the same manner as my regular contributions.
STD FSALDF
05/17/12
Page 1 of 2
I elect to cancel my Catch-Up contribution election.
A03:041012
MITA/225677585
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