Lake Mary 457 Enrollment - Web Book - Ready - Flipbook - Page 19
CITY OF LAKE MARY
457 DEFERRED COMPENSATION 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 options below)
▪
Pre-Tax Contributions:
❑
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.
▪
Catch-up Contributions: If you are taking advantage of either catch-up provision, please check the applicable
box below.
❑
Age 50 catch-up contributions (additional pre-tax deferral of up to $7,500)
❑
▪
Opt out:
❑
Special pre-retirement catch-up contributions (additional pre-tax deferral of up to $22,500 in 2023)
Please include Pre-Retirement Catch-up form.
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: ___________________________