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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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