State Of Tennessee Participant Enrollment Form 401(K) And 457 Plans Page 2

Download a blank fillable State Of Tennessee Participant Enrollment Form 401(K) And 457 Plans in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete State Of Tennessee Participant Enrollment Form 401(K) And 457 Plans with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

What is 401k Enrollment Form and Instructions on filling it out

______________________ _____

______ - ____ - _______

Last Name

First Name

Social Security Number

Investment Options - I understand and acknowledge that all payments and account values, when based on the experience of the investment options, may not be

guaranteed and may fluctuate, and upon redemption, shares may be worth more or less than their original cost. I understand that I may obtain current prospectuses

from my registered representative or online. The State of Tennessee shall be liable only to pay amounts equal to that which would have been available under

the products or contracts described above and shall not be responsible for any loss due to the investment of funds and assets in said Deferred Compensation Plan

account, nor shall the State of Tennessee be required to replace any loss whatsoever which may result from said investments. I acknowledge that investment option

information, include prospectuses, disclosure documents and Fund Profile sheets, have been made available to me and I understand the risks of investing.

List beneficiary(ies) below. If you are participating in both plans, the below beneficiary elections will apply

to both plans, unless you complete separate beneficiary change forms.

Designate Whole

Primary Beneficiary Name(s)

Relationship

Social Security Number

Date of birth

Percentage

___________________________

________________

____________________

__________

_________

___________________________

________________

____________________

__________

_________

___________________________

________________

____________________

__________

_________

Designate Whole

Contingent Beneficiary Name(s)

Relationship

Social Security Number

Date of birth

Percentage

___________________________

________________

____________________

__________

_________

___________________________

________________

____________________

__________

_________

___________________________

________________

____________________

__________

_________

Plan Beneficiary Designation

This designation is effective at the time it is recorded into my account by the State's record keeper, Great-West Retirement Services. I have the right to change the

beneficiary election. If any information is missing, additional information may be required prior to recording my beneficiary designation. Under the terms of the Plan

Document, if I name more than one beneficiary in either category, the surviving beneficiary(ies) in that category will share equally, unless otherwise indicated. If my

primary and contingent beneficiaries predecease me or I fail to designate beneficiaries, amounts will be paid first to an existing spouse, and if there is none, to my estate.

If designating a minor beneficiary, I will note the name of the guardian or parent, if other than myself.

Participation Agreement

I have received a copy of the Deferred Compensation Plan and understand the terms and provisions thereof.

The Deferred compensation Plan is incorporated into this Participation Agreement and that these together constitute my entire rights and obligations under the Plan.

This form is a legally binding contract - I understand that by signing and submitting this Participant Enrollment form for processing, I am requesting to have

investment options established under the Plan(s) specified on the first page of this form. I understand that this account is subject to the terms of the Plan Document.

Account balances shall only be distributed under the terms of the Plan Document, which prohibits any payouts as long as I continue in employment with the State

except in the case of financial hardship as defined by applicable 401(k) plan regulations or at age 59 1/2. Special penalty and limitations may apply to 401(k)

distribution and designated Roth 401(k) deferrals. Limits on 457 hardships are more restrictive than 401(k). Requirements vary by plan.

Compliance with the Internal Revenue Code- I understand that the maximum annual limit on contributions is determined under the Plan Document and/or the Internal

Revenue Code. I understand that it is my responsibility to monitor my total annual limit on contributions to ensure that I do not exceed the amount permitted. If I exceed

the contribution limit I assume sole liability for any tax, penalty, or cost that may be incurred. I understand that Federal income tax is deferred on allowable pre tax

contributions and the earnings thereon, until such amounts are distributed. I understand that Roth 401(k) contributions, earnings, and distributions are treated differently.

I understand that in the event my Participant Enrollment form is incomplete, or it is not received by Great-West's regional office in Nashville, Tennessee prior

to the receipt of any deposits, I consent to Great-West retaining all monies received and allocating them to the default investment option which is selected by my

Plan. Once my account has been established, I understand that I must call KeyTalk in order to transfer monies from the default investment option. Also, I understand

all contributions received after my account is established will be applied to the investment options I selected. I also understand that it is my obligation to review

my confirmations and quarterly statements and inform Great-West of any discrepancies or errors within 90 calendar days of the date of such confirmation or statement.

Plan fees- I understand that fees may apply under this plan.

Required Signature- I have completed, understand, and agree to all pages of this participant enrollment form.

_________________________________________________

__________________

Participant Signature

Date

For more information regarding

This Participant Enrollment form is considered unsolicited unless accompanied be a signed Participant

the 401(k) and 457 plans, visit:

Suitability Profile form completed in the presence of a GWRS Equities, Inc. Registered Representative

during a one-on-one meeting.

or call Great-West Retirement