City Beverages Enrollment - Web Book - Ready - Flipbook - Page 19
CITY BEVERAGES 401(K) PLAN
Enrollment / Information Change Form
Mr. Kent Birckhead
City Beverages, LLC
10928 Florida Crown Drive
Orlando, FL 32824
Certified Benefits Corp
1111 Douglas Avenue
Altamonte Springs, FL 32714
Please complete the following accurately. Print clearly.
SECTION 1: General Information
□
NEW ENROLLMENT
□
INFORMATION UPDATE/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, 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 5%, and Automatic Escalation
at 1% each January 1st until I am deferring 15% of my compensation.
❑
I want to make pre-tax salary deferral contributions to the Plan. I authorize my employer to deduct
_____ .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 deferrals 1% each
January 1st until I am deferring 15% of my compensation.
I do not wish to contribute to the Plan 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: ___________________________