Diocese Enrollment - Web Book - Ready - Flipbook - Page 19
DIOCESE OF ORLANDO EMPLOYEE 403(b) SAVINGS & RETIREMENT PLAN
ENROLLMENT AND PAYROLL DEDUCTION AUTHORIZATION FORM
Please complete the following accurately. Print clearly.
SECTION 1: General Information
❑ Priest
❑ Lay Employee
_______________________________________________
Last Name
First Name
M.I.
_________-_________-_________
Social Security Number
_______________________________________________
Mailing Address
(__________)________-________
Residence Telephone
_______________________________________________
City
State
Zip Code
____________________________
Employer (Name of Parish, School, etc)
_____________________
Date of Birth (mm/dd/yy)
____________________
Date of Hire (mm/dd/yy)
Email Address [REQUIRED FOR SECURITY & ONLINE ACCESS]
□ YES, send my statement electronically
SECTION 2: Contribution Election (please select one of the three options below)
❑
I want to take advantage of the Automatic Enrollment and make pre-tax salary deferral contributions to the Plan.
I authorize my employer to deduct 6.0% 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 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. If this percentage is less than the Automatic Enrollment of 6%, then this percentage will be considered
an affirmative election of a lesser percentage.
❑
I do not wish to contribute to the Plan, and am opting out of the 6% Automatic Enrollment at this time.
__________________________________________
___________________________
Employee Name Print
Date
______________________________________________
Employee Signature
______________________________
Date