401 (K) Plan Contribution Authorization/change Form (Compensation $17,000) printable pdf download

401 (K) Plan Contribution Authorization/change Form (Compensation $17,000)

Division of Human Resources

401 (k) Plan Contribution Authorization/Change Form

Complete all information and return this form to Benefits/Human Resources – ESC-4

Your ID# ____________________________

Name _____________________________________________ Home Phone (

) ________________

Last

First

Address ____________________________________________________________________________

City _______________________________ State ________ ZIP Code __________________________

Work Location ________________________________

Work Phone (

) ____________________

Effective date of change________________________________________________________________

Month/Year

To ensure your change is processed in the month you have requested, this form must be received

by the 15

_________SUSPEND my 401 (k) Plan Deduction

_________CHANGE MONTHLY DEDUCTION: I request a 401(k) Plan monthly contribution of

_____________ % (whole percentage) or $ _____________ to be deducted from my pay.

This amount must be no more than 100% of PERA includible gross (Gross compensation

minus PERA) compensation not to exceed $17,000 annually ($22,500 if over 50).

Signature ________________________________________Date_______________________________

401 (K) Plan Contribution Authorization/change Form (Compensation $17,000)