Fremont 457 Enrollment Form (Page 2 of 2) in pdf

FREMONT 457 ENROLLMENT FORM

SALARY REDUCTION AGREEMENT

Effective with respect to amounts paid or otherwise made available on or after ___________________, 20_____, which date is subsequent to the

execution of this Agreement, the Employee’s salary will be reduced by the amount indicated below. At the same time, the Employer may contribute a

corresponding amount to the Employee’s annuity contract(s) or custodial account(s) maintained under the eligible Internal Revenue Code Section

457 Deferred Compensation Plan, under which the Employee may allocate among the investment options approved by CalSTERS Pension2.

This Agreement shall be legally binding and irrevocable for both the Employer and the Employee with respect to amounts paid or otherwise made

available while this Agreement is in effect. Either party may modify or otherwise terminate this Agreement as of the first pay period commencing with

or during the first month following receipt of satisfactory written notice of such modification or termination by giving at least seven (7) days’ written

notice so that this Agreement will not apply to amounts subsequently paid or otherwise made available.

The amount of the salary deferral shall be as follows:

$______________ per pay period

The amount deferred hereunder will produce a total deferral that does not exceed the applicable limitations of Internal Revenue Code Section 457(b)

and Internal Revenue Code Section 401(v).

PARTICIPANT AUTHORIZATION

I understand that:

An election made on my 457 participation agreement applies only to compensation paid of made available no earlier than the first day of the calendar

month after the calendar month in which the participant agreement is signed.

By completing this form you are directing CalSTRS to allocate funds to investment options offered by the CalSTRS Pension2 457Program.

All of your rights under these funding vehicles are subject to the terms of the CalSTRS Pension2 Program, your school district’s 457, and the

distribution restrictions under the Internal Revenue Code. CalSTRS may decide to cease offering any of these funding vehicles as allocation

options under the plan and, should CalSTRS decide to do so, you may be required to transfer your accumulations in such plan funding

option to another funding option.

I have read and acknowledge all provisions to this form. I acknowledge that I have received and reviewed the Plan Highlights and Fund

Fact Sheets located at

which contain additional information about the CalSTRS Pension2 Program, the Easy Choice Portfolios,

Voya Fixed Plus III and the mutual fund investment options. I certify under penalty of perjury under the laws of the State of California that

the Social Security number provided by me is my correct Social Security number.

PARTICIPANT’S SIGNATURE: ________________________________________________________________

DATE:_____/______/______

The Information Practices Act of 1977 (Civil Code §1798.17) and the Federal Privacy Act of 1974 (Title 5, United States Code §552a(e)(3), §7 Note) require that this notice be provided when collecting personal

information and Social Security numbers from individuals. Information requested on this form is used by CalSTRS, Active Financial Choices for the purposes of identification. Legal references authorizing

solicitation and maintenance of this personal information include Education Code Sections 24950 and 24975, Government Code Sections 1151 and 1153, and Title 26, United States Code (Internal Revenue

Code) Sections 6011 and 6051. It is mandatory to furnish all information requested on this form. Failure to provide the mandatory information may result in the enrollment action not being processed.

Information requested on this form may be shared with the record-keeper, school district and school district’s contracted Third Party Administrator in conjuction with guidelines established by the Internal

Revenue Service in accordance with 457 plans. Copies of the CalSTRS Pension2 Enrollment Form are maintained in confidential files of CalSTRS’ contracted supplemental savings plan administrator for five

years. Enrollees have the right of access to their enrollment forms upon request. The agency official responsible for maintenance of the forms is: California State Teachers’ Retirement System, P.O. Box 15275

MS-44, Sacramento, CA 95851-0275.

Please submit your completed form to:

FAX DELIVERY:

REGULAR MAIL DELIVERY:

OVERNIGHT DELIVERY:

CalSTRS Pension2 Plan Administration

1-888-814-5862

P.O. Box 24747

8900 Freedom Commerce Parkway

Jacksonville, FL 32241-4747

Jacksonville, FL 32256

If you have any questions, please contact a Customer Service Associate at 844-electP2 (844-353-2872) (TTY/TTD users call 800-468-5449) or go online