Nationwide 457 Contribution Change Form - Boone County, Missouri

D Nationwide? Retirement Solutions

NACo Participation Agreement, Payroll Deduction Authorization and Service Request for 457 and 401(a} Plans

~~? c~ ??~ ??.. 0 '

Personal

Name

Information Address

.. on tiio dato-.oeeepU!d~y lt\e Puble SK!ol: ~ ~?

'

:social Securlfy Number

'oate of Birth

. -

D Check

here If this Ia a name change (proof of name change miJsl

City, State, & Zip Code

Email Address

f 457 Plan Name

;contact Phone Number

?Gender (circle one}

Male 3$7 Pion lb

Female

j

I I -

I

!

!

be attached} r1:illHlaJ Plan I"Jome

D Check

~ IJJla} 1'1an 11:1

I

!

h111e If this 11 a Dale of Hire

I

I

new address

Type of Request

D New

(1 Change

D Reinstatement

NOTE: All increases, decreases c1nd suspensions will be implemented no sooner than the first payroll of the month fol-

lowing the change. Pleo$e remember lo check your poystub to confirm your selected contributions ore accurately

reflected and being processed.

Contribution

Summary &

~

~ ~onfrlbutlon Amount- 457 Pre-tax

Payroll

Frequency

~ontributlon Amount- 457 Roth'

Percentage

OR

DollarAmount

;--ontrlbutfon Amount? 401 (o) Pre-Tax ~mp/o_yee Mondatorv Contribution..

a tal

~ ?Moy not be oHered by your pion. Roth contributions ore made on on after-tax basis. Generally, contributions con

start, increase or decrease no earlier than the first day of the month following the month this appllcatlon Is signed.

??Employee Mandatory Conlllbution is a one lime election stated in the Plan Document. This Is Irrevocable and must

be made before the participant's lint entry date. l Start Contribution on:

Payroll Frequency:

D Weekly (W)-52 D Bi-Weekly (Z)-26

D Monthly (M)-12

n Other

D Semi-Monthly (X)-24

Special Pay Period Ending Date 457 Catch-Up

Start

# or pay periods

Stop

DYes, 3-year

0 Yes, Age 50+

Normal Retirement Age

*You must complete the Catch-Up Worksheet in addition to this form.

0 No

Beneficiary Designation

0 Check here If this Is a change of beneficiary. (BeneficiaJies listed below replace any prior designation) PLEASE NOTE: Percentage split rnust total 100% tor each category of beneficiary (I.e. primary and contingent), and must be

. in whole percentc1ges. If additional space for beneficiaries is required. atl-ach additional sheets and mark this box: 0

[llenenclary Name

lsoclol Security Number

j(o'Splif

D Primary 0 Contingent jAaaress

loore or 111nn jrnoneN

jllenenclary Name D Prima ry D Contingent Aaaress

~ DC-4641-0513

l:soc:tat ~ec:umy N.umc~n

7o~pnr

.rare or lllnn rnonew

3

Funding Options are on the next page

Funding Options

AO.cortlribuHon1 wlft uie tile agme ? ln'l?tlment elecHon ono:tolloCClhon.\f

Hyou WrsWto h11Ve

dllle.rel'!ttelecfloni, c911tact o Customer ServiCe Represeniotlve at 1-Bn-677-3678.

,..

Authorization

Pre-tax and Roth contributions will use the same Investment election and allocation. If you wish to have different selections, contact a Customer Service Representative at 1-877-677-3678.

Ailll.&l.'.~..N ., .NAll!IR~!!IJ:~JaWI. Q.UIUU',JJ.Qm...ll!JU _ __ % Noti!')'Nidelinotion 2015 rund

(lnstitulio?1a! Service Closs]

--?----. .........- ...% hlolionwirJc'.fD Dest!notion 2020 Fund

llnstifutionoi Servic:e Clc155) - ??----..?---- .....% Nationwide-? Destination 2025 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download