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401(k) PlanEconomic Growth and Tax Relief Reconciliation Act of 2001 (EGTRRA)Catch-Up Contribution Election FormENROLLMENT AND PAYROLL DEDUCTION CHANGE AUTHORIZATION(Please print legibly and complete all sections fully)Participant Information:Social Security # ________________________Name: _________________________________Sex: _____ Marital Status: _________________Date of Birth*:_______________ Address: ________________________________________ Phone#:_______________________________Hire: _________________________________* EFTRAA requires you must be 50 years or older prior to December 31, 2015 to qualify for this benefit.Designated Beneficiary:□ My 401K Beneficiary has previously been designated.□ a new Beneficiary Designation for my 401K Plan is attached.Contribution (Payroll Deduction) Authorization.Traditional 401(k) Pre-tax□ I authorize regular payroll deductions, effective _____________________for the purpose of making salary deferral contributions to this catch-Up Plan in the following dollar amount: _______ flat amount of all regular bi-weekly paycheck. Roth 401(k) Post-tax□ I authorize regular payroll deductions, effective _____________________for the purpose of making salary deferral contributions to this catch-Up Plan in the following dollar amount: _______ flat amount of all regular bi-weekly paycheck. These Catch-Up Contributions will be invested in the mutual fund selections previously designated. ____________________ ________________________________________ Employee Signature Date ................
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