Paycheck Contribution Election Governmental …

Paycheck Contribution ElectionGovernmental 457(b) PlanSTD FSALDF ][12/14/17)(98993-01NO_GRPG 58073/][GU22)(/][GP22 DOC ID: 510091916)(Page 1 of 4 CERF Savings plan - 457 Plan98993-01 Use black or blue ink when completing this form. For questions regarding this form, visit the Web site at or contactService Provider at InformationAccount extension, if applicable, identifies fundstransferred to a beneficiary due to participant'sdeath, alternate payee due to divorce or aparticipant with multiple ExtensionSocial Security Number (Must provide all 9 digits)Last NameFirst ( )Daytime Phone Number( )Alternate Phone NumberI have a retirement savings account with a previous employer or an IRA. Yes or NoBPayroll Election (s) Paycheck Contribution Election (Payroll Deductions)Select One: Start Restart Change StopI elect to contribute to the plan the following of my eligible compensation indicated below (per pay period): Before Tax contributions $_____ or _____% (up to $18, or 1% - 100%)Date of Hire (mm/dd/yyyy) / / The total annual before-tax contributions cannot exceed $18, of my eligible compensation in the 2018 tax ElectionAge 50 457 Catch-Up:I el

Paycheck Contribution Election Governmental 457(b) Plan STD FSALDF ][12/14/17)(98993-01NO_GRPG 58073/][GU22][GP22DOC ID: 510091916)(Page 1 of 4 CERF Savings Plan - 457 Plan 98993-01

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