State Employees' Deferred Compensation Plan Enrollment Form

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CMS

I L L I N O I S

DEPARTMENT OF CENTRAL

MANAGEMENT SERVICES

P.O. Box 19208, Springﬁ eld, IL 62794-9208

STATE EMPLOYEES' DEFERRED COMPENSATION PLAN

ENROLLMENT FORM

Please type or print clearly in ink. Initial any corrections, additions, deletions or changes in pen. Complete all sections.

For more information, call the Deferred Compensation Ofﬁ ce at 1-800/442-1300, 1-217/782-7006 or TDD/TTY 1-800/526-0844.

Last Name

First

Middle Initial

Social Security Number

Date of Birth

Street

City

State

Zip Code

Agency or University

Ofﬁ ce Phone Number

Home Phone Number

(

)

(

)

Work Address

Payroll Code (5 digits - refer to your pay stub)

SECTION A: TRANSACTION TYPE

Initial Enrollment

Re-enrollment of a Former Participant

SECTION B: AMOUNT OF DEFERRAL

- The minimum deferral is $10 per pay period or $20 per month, whichever is greater. Indicate the amount

to be deducted from each paycheck in the space below. Deferrals can begin no sooner than the ﬁ rst pay period of the next month. By completing this

section and signing this form you are electing to participate in the State Employees' Deferred Compensation Plan and are authorizing the State of Illinois

to defer from your total compensation the following from each pay period until your termination, modiﬁ cation or revocation of this amount:

$__________________ per pay period beginning with the

ﬁ rst

second pay period in _____________ (mo/yr).

SECTION C: INVESTMENT REQUEST -

Select one or a combination in which to invest your deferrals. The percentages must total 100%

and must be in whole numbers with no fractions. I hereby request that my Deferred Compensation deferrals be invested in the following manner:

These funds are the options if you want to select your own investment mix.

These funds are one-step options that make

______ %

it easy for you to invest for retirement. Simply

Vanguard Prime Money Market Fund Inst. Shares/VMRXX (money market)

choose the fund with a target date closest to the

______ %

INVESCO Stable Return Fund (stable value)

year in which you plan to retire and your funds will

be managed for you.

______ %

Vanguard Total Bond Market Index Fund/VBTIX (core ﬁ xed income)

T. Rowe Price Retirement Funds:

______ %

T. Rowe Price Bond Trust I (core ﬁ xed income)

______ %

Retirement 2060 Active Trust

Fidelity Puritan Fund/FPURX (U.S. balanced)

______ %

Retirement 2055 Active Trust

Vanguard Institutional Index Fund/VINIX (large company core)

______ %

Retirement 2050 Active Trust

LSV Value Equity (large-company value)

______ %

Retirement 2045 Active Trust

Wellington Trust Diversiﬁ ed Growth Portfolio (large-company growth)

______ %

Retirement 2040 Active Trust

Franklin Small Cap Growth Fund, R6/FSMLX (small-company growth)

______ %

Retirement 2035 Active Trust

Ariel Fund Separate Account (mid-sized company value)

______ %

Retirement 2030 Active Trust

Invesco International Growth Equity Trust (non-U.S. large company growth)

______ %

Retirement 2025 Active Trust

______ %

William Blair Int'l Small Cap Growth Fund/WISIX (non-U.S. small-co growth)

______ %

Retirement 2020 Active Trust

Northern Trust ACWI ex US Fund (non-U.S. large company core)

______ %

Retirement 2015 Active Trust

Northern S&P 400 Index Fund (mid-sized company core)

______ %

Retirement 2010 Active Trust

______ %

Northern Trust Russell 2000 Index Fund (small-company value)

______ %

Retirement 2005 Active Trust

______ %

Retirement Balanced Active Trust

READ THIS INFORMATION COMPLETELY BEFORE SIGNING

I hereby acknowledge receipt of a copy of the Plan and agree to the terms and conditions. I hereby acknowledge that I have received and read a prospectus

for each mutual fund in which I am investing. I understand and acknowledge that all amounts of compensation deferred pursuant to the Plan and all income

attributable to such amounts shall be held in one or more custodial accounts for the exclusive purpose of participants and beneﬁ ciaries under the Plan. I

understand that participation in the Deferred Compensation Plan is a beneﬁ t offered by the State of Illinois. In return for this beneﬁ t, I and my heirs, succes-

sors, and assignees shall hold harmless the State and its employees, ofﬁ cials, agents, assignees, and successors from any liability for all acts in good faith.

SIGNATURE X ______________________________________________________________ DATE

Send completed form to your Agency Liaison - or send directly to the Department of Central Management Services.

Liaison

Approval of Deferred Compensation Ofﬁ ce required before

any transaction takes place.

Name _______________________________ Agency _________________________

Date

Date ________________________________ Phone No.________________________

In compliance with the State and Federal Constitution, the Illinois Human Rights Act, the Americans with Disabilities Act and Section 504 of the Federal Rehabilitation Act, the Department of Central Man-

agement Services does not discriminate in employment, contracts, or any other activity.

IL 401-1093

OOM28-ILDC (Rev. 03-2015)