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Paycheck Contribution Election Governmental 457(b) Plan
www.fascore.comPaycheck Contribution Election Governmental 457(b) Plan Use black or blue ink when completing this form. For questions regarding this form, contact Service Provider at 1-866-737-7457. 98978-01 Commonwealth of Pennsylvania Deferred Compensation Program A Participant Information
Paycheck Contribution Election Governmental 457(b) Plan
www.mocerf.orgSTD FSALDF ][12/14/17)(98993-01NO_GRPG 58073/][GU22][GP22DOC ID: 510091916)(Page 3 of 4 Underutilized Amounts Worksheet for Special §457 Catch-Up Begin with the first year you became eligible to participate in this Plan.