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401(k) Deferral Change Form
Member Name:
Social Security Number:
Division:
Male
Female
Date of Birth: ____/____/____ Date of Original Employment: ___/___/___
This is to authorize payroll to deduct:
_________ % (1% to 100%) of my current and future salary per pay period (enter 0% if you choose to stop deferral).
OR
$_________ fixed dollar amount per pay period.
This agreement applies to amounts earned until changed by me in writing. I understand my plan sponsor may reduce my deferral only when required to meet certain plan limits.
MEMBER SIGNATURE:
Date: ____/____/____
PLEASE NOTE THAT DEFERRAL CHANGES ARE EFFECTIVE QUARTERLY. YOU MAY STOP DEFERRING AT ANY TIME.
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