Automatic Contribution Arrangement Election - The Retirement Advantage Page 2
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2Deferrals irrevocable once made. I understand: (1) my election regarding the amount and type of
deferrals is irrevocable once the employer withholds the deferrals from my paycheck; and (2) any change
of election regarding the amount or type of deferrals is effective only for deferrals from paychecks I
receive after the Plan Administrator accepts my change of election.
SECTION 3: SPECIAL ELECTION FOR BONUSES
(Complete this section if Plan allows special elections for bonuses AND you wish to
apply a special election to bonuses)
I authorize the Employer to withhold from my bonus and treat as PRE-TAX salary deferrals the
following amount:
_______% or $__________ of my bonus which is to be paid on ___________________
__________, 2__________ (insert date). In making this election, I do not intend to change my
existing Salary Deferral Agreement (if any) as to Compensation other than the bonus described in
this Agreement (if allowed by Plan).
_______% or $__________ of ALL bonuses paid to me on or after __________________
_________, 2___________ (insert date). In making this election, I do not intend to change my
existing Salary Deferral Agreement (if any) as to Compensation other than the bonus described in
this Agreement (if allowed by Plan).
I understanding that I can change this election at any time by completing a new Salary Deferral
Agreement.
SECTION 4: REQUIRED SIGNATURES
Duty to review pay records. I understand I have a duty to review my pay records (pay stub, etc.) to
confirm the Employer properly has implemented my salary deferral election. Furthermore, I have a duty
to inform the Plan Administrator if I discover any discrepancy between my pay records and this Salary
Deferral Agreement. I understand the Plan Administrator will treat my failure to report any withholding
errors for any payroll to which my Salary Deferral Agreement applies, by the cut-off date for the next
following payroll, as my affirmative election to defer the amount actually withheld (including zero).
However, I thereafter may modify my deferral election prospectively, consistent with the Plan terms.
___________________________________________________
_________________________
Participant Signature
Date
PLEASE RETURN THIS FORM TO THE PLAN ADMINISTRATOR
2/10
ACA Agreement
Page 2 of 2
(Please Complete All Pages)
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