Paycheck Contribution Election Governmental 457(b) Plan
Transcription
Paycheck Contribution Election Governmental 457(b) Plan
Paycheck 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 A Participant Information Social Security Number Account Extension (If applicable) Last Name Last Name First Name First Name M.I. M.I. Street Address Street Address City State City Email Address State B City Employee Number Number Employee Email Address Email Address Payroll Election(s) B O i P ll D d Payroll Election(s) Election Zip Code Zip Code / / State Zip Code Date of Hire (mm/dd/yy) Account extension identifies funds transferred to a beneficiary due to death, alternate payee due to divorce or a participant with multiple accounts. / Date of Birth / (Date of) Birth / / (Personal ) Phone Number (Personal ) Phone Number Work Phone Number ( ) ❑ Married Unmarried Work Phone ❑ Number ( ) Work Phone Number Dept. of Employment (Ex. DPW, L & I, St. Police) ❑ Married ❑ Unmarried / / / / Employee Number Number Date of Agency Employment (Ex:DPW, DPW, I,St. St.Polic Police) Employee Dept.THAT ofof Employment (Ex. &&I, MADE. PAYROLL ELECTIONS MUST BE ENTERED INTO PRIOR TOHire THE(mm/dd/yy) FIRST DAY OF THE MONTH THE DEFERRAL WILLL LBE Employee Number Number Date of Hire (mm/dd/yy) Employee Dept. of Employment (Ex. DPW, L & I, St. Police) i Retirement Date❑ StartMUST ❑ Select One: PAYROLL ELECTIONS BERestart ENTERED INTO PRIOR TO ❑ THE FIRST DAY OF THE MONTH THAT THE DEFERRAL WILL BE MADE. Stop ❑ Change Payroll Deduction: elect to to contribute contribute to $ the Plan the following amount(s) of my sick and annual leave of payout. (An indication of Whole or Full will not be processed.) (per pay period): II elect or percentage(s) my eligible compensation as indicated below (PER PAY PERIOD): Catch-UpPayroll Provision (if applicable) Ongoing Deductions: Sick and Annual Leave MUST Deduction Only: (PAYROLL ELECTIONS BE ENTERED INTO PRIOR TO THE FIRST DAY OF THE MONTH THAT THE DEFERRAL WILL BE MADE.) Retirement Date❑ Start Catch-Up Provision Utilized - If eligible for❑ both types of Catch-Up Select One: ❑ Stop this year, I may select either Age 50 §457 Catch-Up or Special §457 Catch❑I am Restart Change Up, whichever would$result in the larger Catch-Up forannual this calendar year. (An indication of Whole or Full will not be processed.) elect to contribute contribute of myamount sick and leave of payout. (per pay period): II elect to to the Plan the following amount(s) or percentage(s) my eligible compensation as indicated below (PER PAY PERIOD): Age 50 Age 50 §457 §457 Catch-Up Catch-Up -- II must must be be age age 50 50 or or older older by by the the end end of of this this calendar calendar year year and and II may may not not use use Special Special §457 §457 Catch-Up Catch-Up this this year. year. The The total total before-tax Before-Taxand Contributions $ or %eligible ($5.00 - $17,000.00 or - 100%) $17,500.00 2014 before-tax and Roth Age Catch-Up exceed compensation in 2014 tax Roth Age 50 50 §457 §457 Catch-Up amount amount cannot cannot exceed $5,500 $5,500 of of my my eligible compensation in the the.5% 2013 tax year. year. When When added added to to the the contribution amount, the the aggregate maximum maximum available available is $23,000 $23,000 of of my my eligible eligible compensation in the the 2014 tax year. basic contribution amount, is compensation in year. basic Roth Contributions $ aggregate or % ($5.00 - $17,000.00 or 2013 .5% -tax 100%) $17,500.00 Catch-Up -- II understand the $17,500 in Special §457 Catch-Up understand the total total Special §457 Catch-Up amount amount cannot exceed $17,500 of my my eligible eligible compensation in 2014. 2013. D t cannot f Hi exceed ( /dd/ ) of / compensation / P Special llOne: Eff §457 i D ( /dd/ ) / Special /§457 Catch-Up Retirement Date Select ❑ maximum Stop Start ❑ Restart amount, ❑ Change When to basic the available When added added ❑ to the the basic contribution contribution amount, the aggregate aggregate maximum available is is $35,000 $35,000 in in 2014. 2013. II understand understand that that by by electing electing to to begin begin elect to contribute contribute $ the Plan of my and annual payout. (An indication Whole or Full notof: be processed.) Special §457 contributions, shall be sick deemed to elect as Retirement Age the earlier (1) the calendar year (per pay period): II elect to to the following amount(s) or percentage(s) of my eligible compensation asyear indicated below (PER PAY PERIOD): Special §457 Catch-Up Catch-Up contributions, II shall be deemed to elect leave as a a Normal Normal Retirement Ageof(NRA) (NRA) year the will earlier of: (1) the calendar year in in which rst contribution which II reach reach age age 70 70 1/2, 1/2, or or (2) (2) the the fourth fourth calendar calendar year year from from the the date date of of the thefifirst contribution under under this this Special Special §457 §457 Catch-Up Catch-Up election. election. During During the Before-Tax Contributions $ attained or age % ($5.00 - $17,000.00 or .5% - retirement 100%) $17,500.00 to for benefits the elected elected NRA NRA year, year, II will will have have attained the the appropriate appropriate age and/or and/or years years of of service service to be be eligible eligible for unreduced unreduced retirement benefits under under my my basic retirement retirement plan. plan. NRA may may not not be be changed in third of §457 Catch-Up. II must Employer’s Roth Contributions Employer’s basic NRA changed in my my second second and and % third year year of Special §457 or Catch-Up. must have have “underutilized “underutilized $ or ($5.00 -Special $17,000.00 .5% - 100%) $17,500.00 amounts” by not not contributing contributing the the maximum maximum amount amount available to me me under under this this Plan Plan in II was amounts” by available to in any any prior prior calendar calendar years years in in which which was eligible eligible to to 2014 D t forf Special Hi ( §457 /dd/ Catch-Up ) / / P participate. llOne: Eff Date i II have D (calculated /dd/ the ) total / ❑ IStop Retirement Select have calculated total underutilized amounts participate. underutilized amounts I have have available available for Special §457 Catch-Up using using the the attached attached underutilized underutilized ❑ Start ❑ the Restart ❑/ Change amounts worksheet as below, have attached the page worksheet. The tools are provided for my convenience and amounts worksheet as indicated indicated below, and and have attached the third third page worksheet. The calculation calculation are will provided for my convenience elect to contribute contribute $ the of my sick and annual leave payout. (An indication of Whole or Full not be processed.) (per pay period): II elect to to Plan the following amount(s) or percentage(s) of my eligible compensation astools indicated below (PER PAY PERIOD): and II should tax advisor advisor about about my my tax tax situation. situation. should consult consult with with my my tax Before-Tax Contributions $ or % ($5.00 - $17,000.00 $17,500.00 or .5% - 100%) Underutilized Amount: $_______________________ Roth Contributions $ or % ($5.00 $17,000.00 $17,500.00 or .5% - 100%) I elect to cancel my Catch-Up contribution election. (mm/dd/yyyy) / / Date of Hire Payroll Effective Date (mm/dd/yyyy) / / Payroll Deduction Ongoing Payroll Deductions: Sick and Annual Leave MUST Deduction Only: (PAYROLL ELECTIONS BE ENTERED INTO PRIOR TO THE FIRST DAY OF THE MONTH THAT THE DEFERRAL WILL BE MADE.) Retirement Select One:Date This election will all Restart previous contribution The total annual before-tax and Roth contributions combined cannot ❑ Stop ❑supersede Start ❑ ❑ Change elections. exceed of eligible compensation tax year, unless catch-up provision has been elected. 2014 elect to to$17,500 contribute $ the Plan ofthe my 2013 sick and annual leave of payout. (An indication of Whole or Full will not be processed.) (per pay period): II elect contribute to the followingin amount(s) or percentage(s) my eligible compensation as indicated below (PER PAY PERIOD): Retirement Date❑ Start Select One: ❑ Changeor ❑ Stop Before-Tax Contributions ❑$ Restart % ($5.00 - $17,000.00 $17,500.00 or .5% - 100%) II elect l ib $to the Plan the followingf amount(s) i k dor percentage(s) ll to Contributions contribute of my eligible compensation as indicated below ($5 or .5% minimum Roth $ or % ($5.00 - $17,000.00 or .5% - 100%) $17,500.00 contribution) (PER PAYCHECK): Date of Hire (mm/dd/yyyy) / / Payroll Effective Date (mm/dd/yyyy) / / Retirement Before-Tax Contributions $ Restart or % Select One:Date ❑ Stop ❑ Start ❑ ❑ Change $ elect toContributions contribute to $ the Plan $the following amount(s) of my sick and annual leave of payout. (An indication of Whole or Full will not be processed.) Rothto or percentage(s) % (per pay period): II elect contribute or my eligible compensation as indicated below (PER PAY PERIOD): Date Payroll EffectiveContributions Date (mm/dd/yyyy) / Before-Tax $ or / % ($5.00 - $17,000.00 $17,500.00 or .5% - 100%) I dd t Contributions ddthh t thLeave l l b f$ l bt f d R thd R t h ib or ti ib i t d $17 5 0 l Deduction: Roth ($5.00 - $17,000.00 or .5% - 100%) $17,500.00 Sick and Annual Sick and Annual Leave Deduction (Will be forwarded to your payroll % department for processing) _____________ Retirement Date Date Payroll Effective (mm/dd/yyyy) / / I elect to contribute to the Plan the following amount(s) of my sick and annual leave payout: (An indication of Whole or Full will not be processed.) I understand the total annual before-tax contributions cannot exceed $17,000.00 of my eligible compensation in the 2012 tax year. Before-Tax Contributions $_________________ ❑ Before-Tax Contributions $ or % ($5.00 - $17,000.00 or .5% - 100%) Roth Contributions $_________________ Retirement Select D t fOne: Hi Date ( ❑ /dd/ ) / / ❑ Stop Startsick & annual ❑ Restart ❑ Change Please Note: If the net leave payout amount is not sufficient to attain the requested deferral amount, the deferral will be deducted electthe to ficontribute contribute $ the Plan the following amount(s) of my sick and annual leave of payout. (An indication of Whole or Full will not be processed.) (per pay period): IIfrom elect to to or percentage(s) my eligible compensation as indicated below (PER PAY PERIOD): nal paycheck. A03:041012 STD FSALDF 7/10/14 Page 1 of 3 DACA/Manual (SR 870576) A02:122112 ][ JNEW/311880198 ,JNEW/Manual (SR 118800) ][ 98978-01 Last Name C First Name MI Social Security Number Number Participant Consent My signature signature acknowledges acknowledgesthat thatI have I haveread, read, understand and agree to pages all pages of the Contribution Election that and Iaffirms that all My understand and agree to all of this formPaycheck and affirms that all information have provided is true and correct. I alsoprovided understand that:and correct. I also understand that: information that I have is true M Until cancelled, superseded or I cease to be an eligible employee, this election shall apply to all eligible compensation allowed by the Plan paid from the effective date specified unless a different effective date is required under the terms of the Plan and cancels all previous elections. M Payroll elections must be entered into prior to the first day of the month that the deferral will be made. M I may change the dollar amount or percentage of compensation contributed as allowed under the terms of the Plan. M It is my responsibility to comply with any Internal Revenue Code deferral limits and that I may be responsible for any costs, including taxes and penalties that I may incur as a result of excess contributions. M My Plan Administrator/Trustee may take any action that may be necessary to ensure that my participation is in compliance with any applicable requirement of the Plan Document and the Internal Revenue Code. M I authorize the payroll deduction as indicated on this form. Any person who presents false or fraudulent information is subject to criminal and civil penalties. Participant Signature D Date (Required) Mailing Instructions Participant forward to Great-West Retirement Services® Great-West Retirement Services® please retain this document for your records. Payroll elections are not maintained by Service ® Great-West Provider. Retirement Services PO Box 173764 ® Great-West Retirement Services® Denver, CO 80217-3764 301 Chestnut St., Suite 402 Phone #: 1-866-737-7457 Harrisburg, PA PA 17101 17101 Fax #: 1-866-745-5766 Phone #: 1-866-737-7457 Fax #: 1-717-901-3620 Great-West FinancialSM refers to products and services provided by Great-West Life & Annuity Insurance Company (GWL&A), Corporate Headquarters: Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York (GWL&A of NY), Home Office: White Plains, NY; its subsidiaries and affiliates. The trademarks, logos, service marks, and design elements used are owned by GWL&A. A03:041012 STD FSALDF 7/10/14 Page 2 of 3 DACA/Manual (SR 870576) A02:122112 ][ JNEW/311880198 ,JNEW/Manual (SR 118800) ][ Underutilized Amounts Worksheet for Special §457 Catch-Up Begin with the first year you became eligible to participate in this Plan. Ignore all prior years. Instructions: 1. Multiply your includible compensation by the percentage in column A, and enter this amount in column A (includible compensation). a. For years prior to 2002, includible compensation is equivalent to the amount shown on the W-2 in Box 1 (or Box 10 for years prior to 1993). b. For 2002 and thereafter, includible compensation is equivalent to the amounts shown on the W-2 in Box 1, PLUS any amounts received from your employer as a qualified transportation fringe benefit, any amounts deferred under a §125 cafeteria plan and any contributions to a §401(k), §403(b) and §457(b) plan. 2. In column C, enter the lesser of the amount in column A (includible compensation) or B (basic annual §457(b) contribution limit). 3. From column C, subtract columns D (actual contributions) and E (other contributions) and enter that amount in column F (underutilized amount). 4. Add totals from column F in the TOTAL UNDERUTILIZED AMOUNTS line at the end of the worksheet; this is your total underutilized amount. 5. You may only use an underutilized amount equal to the current year’s basic annual §457(b) contribution limit. Any remaining underutilized amount may be contributed in any remaining special catch-up years, up to an amount equal to that year’s basic annual §457(b) contribution limit. 6. NRA may not be changed in your second and third year of catch-up and you must subtract the Special §457 Catch-Up amounts you contributed in a prior year from the total underutilized amounts to determine your remaining underutilized amounts. A Calendar Year 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 3 2012 B Includible Compensation (See instruction #1) 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ =$ C Basic §457(b) Contribution Limit $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $8,000 $8,000 $8,000 $8,500 $11,000 $12,000 $13,000 $14,000 $15,000 $15,500 $15,500 $16,500 $16,500 $16,500 $17,000 $17,500 $17,000 Total Underutilized Amounts (Column F) Lesser of A or B $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ D E F Contributions to another 457(b), Actual 403(b) or 401(k) for Years Underutilized Contributions to Prior to 2002 and thereafter, Amount this 457(b) Plan only to another §457(b) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Prior Special §457 Catch-Up Contributions, if any (Column E) -$ (subtract) Total Underutilized Amounts Remaining =$ (equals) Great-West FinancialSM refers to products and services provided by Great-West Life & Annuity Insurance Company (GWL&A), Corporate Headquarters: Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York (GWL&A of NY), Home Office: White Plains, NY; its subsidiaries and affiliates. The trademarks, logos, service marks, and design elements used are owned by GWL&A. A03:041012 STD FSALDF 7/10/14 Page 3 of 3 DACA/Manual (SR 870576) A02:122112 ][ JNEW/311880198 ,JNEW/Manual (SR 118800) ][