Form Dc-4621-0715 - Nationwide Retirement Solutions Payroll Authorization Card Form
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1Nationwide Retirement Solutions Payroll Authorization Card
(Please complete and submit to your Payroll Center)
I. Personal Information
II. Plan Information*
Plan Type: c 457(b) c 401 (a) c IRA Product
(Check only ONE plan type. If you have several plan types, then
______ - ______ - ______
_____ - _____ - _____
you must submit a payroll authorization card for each plan type.)
Social Security Number
Date of Birth
Action: c Initial c Increase c Decrease c Cancel
__________________________________________________
OLD
NEW
Name
Pre-tax contribution: $_____ or _____% $_____ or _____%
Roth contribution:
$_____ or _____% $_____ or _____%
__________________________________________________
(457(b) Plan Only)
Address
*You may make both pre-tax and Roth contributions.
__________________________________________________
Frequency: c Bi-weekly c Monthly c Other ______
Additional Address
Payroll Deduction to begin on: (Date)_________________
__________________________________________________
Catch Up Provision Utilized*: (select one option)
City
State
Zip Code
c Yes, 3-year c Yes, Age 50+ c No
Normal Retirement Age:________
______________________
(
) - ______ - ______
* Contact Nationwide® at 1-877-NRS-FORU for further information on how
catch up provisions work.
Department
Work Phone
The earliest your enrollment or contribution change can start
is the first day of the month following your completed request.
Please remember, your employer’s processing schedule will
determine the actual effective date of the contribution. It is the
_____________________________________________
Plan Sponsor’s/Pay Center’s responsibility to ensure deferrals do
not commence too early.
Participant Signature
I authorize my employer to reduce my salary by the above
amount for credit to my account with my employer’s Deferred
Compensation Plan. This reduction will begin on the pay period
_____________________________________________
specified above, but no sooner than is permitted by law or than is
Date
administratively practicable. This reduction will continue until
otherwise authorized by my employer in accordance with the
Plan.
DC-4621-0715
Original-Payroll Center Copy-Participant
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Parent category: Business