Certified Financial Enrollment - Web Book - Ready - Flipbook - Page 21
CERTIFIED FINANCIAL GROUP, INC. 401(k) & PROFIT SHARING PLAN
Enrollment / Information Change Form
Certified Financial Group, Inc.
1111 Douglas Avenue
Altamonte Springs, FL 32714
Certified Benefits Corp
1111 Douglas Avenue
Altamonte Springs, FL 32714
Please complete the following accurately. Print clearly.
SECTION 1: General Information
□
NEW ENROLLMENT
□
INFORMATION CHANGE
_______________________________________________________________________
Last Name
First Name
M.I.
_________-_________-_________
Social Security Number
_______________________________________________________________________
Mailing Address
_____________________
Date of Birth (mm/dd/yy)
_______________________________________________________________________
City
State
Zip Code
____________________
Date of Hire (mm/dd/yy)
(__________)__________-__________
Home Telephone
(__________)_________-__________
Mobile Phone [REQUIRED FOR SECURITY & ONLINE ACCESS]
_______________________________________________________________________
Email Address [REQUIRED FOR SECURITY & ONLINE ACCESS]
□
YES, send my statement electronically (please include email address for notification)
SECTION 2: Contribution Election
IMPORTANT NOTE: This Plan includes an automatic contribution feature. Under this feature (effective only for
employees hired after March 15th, 2018), IF YOU DO NOT COMPLETE AND RETURN THIS SALARY
DEFERRAL AGREEEMENT, your Employer WILL AUTOMATICALLY DEFER a portion of your
compensation to the Plan on a pre-tax basis.
❑
I want to take advantage of the Automatic Enrollment pre-tax deferrals at 6%, and Automatic Escalation at
2% each January 1st until I am deferring 10% of my compensation.
❑
I want to make pre-tax salary deferral contributions to the Plan. I authorize my employer to deduct $_________
or _______.0% of my gross salary from each paycheck (not to exceed a total of $22,500 in 2023 if under the age
of 50, or $30,000 in 2023 if age 50 or over) and to credit that amount to my pre-tax salary deferral portion of my
account.
❑ I want to take advantage of the Automatic Escalation by increasing my pre-tax deferrals 2% each
January 1st until I am deferring 10% of my compensation.
❑
I want to make post-tax (Roth 401(k)) salary deferral contributions to the Plan. I authorize my employer to deduct
$________ or ________.0% of my salary from each paycheck and to credit that amount to my post-tax salary
deferral portion of my account.
❑ I want to take advantage of the Automatic Escalation by increasing my post-tax deferrals 2% each
January 1st until I am deferring 10% of my compensation.
❑
I do not wish to contribute to the Plan and am opting out of the 6% Automatic Enrollment at this time.
Signature – Please review to make sure that you have completed each accurately, fully, and legibly. Please return this
form to your employer for acceptance.
Employee Signature: __________________________________________Date: ___________________________
Employer Signature: __________________________________________Date: ___________________________