Automatic Contribution Arrangement Election - The Retirement Advantage
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1
2AUTOMATIC CONTRIBUTION ARRANGEMENT
SALARY DEFERRAL AGREEMENT
Plan Name: ______________________________________________________________________
Participant Name: _________________________________________________________________
Print or Type Complete Legal Name – First, MI, Last
Social Security Number: ___________________________________________________________
Street Address: ___________________________________________________________________
City: _____________________________
State: ______________
ZIP: ____________
Check One:
New Agreement
Change
SECTION 1: CONTRARY DEFERRAL ELECTION
In accordance with provisions of the Plan’s Automatic Contribution Arrangement (“ACA”) permitting
Participants to make salary deferrals under an election which differs from the automatic deferral
percentage described in the ACA Notice I received, I do not wish the Plan’s automatic deferral
percentage to apply to my Compensation. I hereby make the following contrary deferral election:
No salary deferrals. I elect not to make salary deferrals under the Plan. [Note: If you elect not
to defer, sign and date but do not complete the rest of this form. You must make this election if you do
not have an existing Salary Deferral Agreement in place and wish to make no salary deferrals to the
Plan. Also make this election if you wish to terminate a prior Salary Deferral Agreement now in
effect.]
Election to override automatic deferral/change. I elect to defer an amount which is greater or
less than the automatic deferral amount or to change my existing Salary Reduction Agreement.
[Note: If you elect to override the automatic deferral amount (other than to elect “no deferrals” above),
you must complete the rest of this form. If you are changing the amount of your existing deferral
election, complete the rest of this form. If you also wish to change your investment election, you must
complete the investment election form the Plan Administrator will provide you for that purpose.]
COMPLETE THE REST OF THIS FORM ONLY IF YOU ELECTED “Election to override
automatic deferral/change” above.
SECTION 2: SALARY REDUCTION/DEFERRAL AMOUNT
This election is effective as soon as the Plan Administrator reasonably can implement your election after
receipt. I may modify this Agreement only in accordance with current Plan provisions and IRS
regulations:
I authorize the Employer to withhold from my Compensation (and treat as salary deferrals) the
following amount:
$__________ or ______% of my per pay period Compensation as pre-tax salary deferrals
2/10
ACA Agreement
Page 1 of 2
(Please Complete All Pages)
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