City of Lake Mary MPP Enrollment - Web Book - Ready - Flipbook - Page 19
CITY OF LAKE MARY
GENERAL EMPLOYEES PENSION PLAN
Enrollment / Information Change Form
City of Lake Mary
Attn: Human Resources
100 N. Country Club Road
Lake Mary, FL 32746
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 (please select from the options below)
You may elect to make an irrevocable election to contribute 2.5% of earnings on a pre-tax basis OR you may elect
to make a Voluntary After-Tax contribution. Please note that the total contribution limit for the Plan is 15% in 2023.
This includes both Employee (2.5%) and Employer (12.5%) contributions.
CHOOSE ONLY ONE OPTION BELOW:
❑
I want to make pre-tax salary deferral contributions to the Plan. I authorize my employer to deduct 2.5% of
my gross salary from each paycheck and to credit that amount to my pre-tax salary deferral portion of my
account.
❑
I want to make Voluntary after-tax salary deferral contributions to the Plan. I authorize my employer to
deduct __________ .0% up to 2.5% of my salary from each paycheck and to credit that amount to my
voluntary after-tax salary deferral portion of my account.
❑
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: ___________________________
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