Lake Mary 457 Enrollment - Web Book - Ready - Flipbook - Page 21
CITY OF LAKE MARY
457 DEFERRED COMPENSATION PLAN
Pre-Retirement Catch-up 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: Declaration of Normal Retirement Age
I hereby designate age ____, which I will attain in the year _____, as my Normal Retirement Age for the purpose of
using the “Pre-Retirement” catch-up provision. I understand that:
▪
I will be eligible to take advantage of the special pre-retirement catch-up provision only in the three years
immediately preceding the year of my declared Normal Retirement Age only. (For example: if I attain my
declared Normal Retirement Age in 2023, I will be eligible to make catch-up contributions in 2020, 2021
and 2022.)
▪
This election is irrevocable after I begin using the pre-retirement catch-up provision.
SECTION 3: Contribution Amount
❑
I want to make pre-tax salary deferral contribution of $__________ or __________ .0%.
SECTION 4: Total Unused Deferrals
Total Unused Deferrals $__________
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: ___________________________