Parkinson's Enrollment - Web Book - Ready - Flipbook - Page 21
PARKINSON’S FOUNDATION RETIREMENT PLAN
Enrollment / Information Change Form
Certified Benefits Corp
1111 Douglas Avenue
Altamonte Springs, FL 32714
Fax: 407-682-1748
Parkinson’s Foundation, Inc.
200 SE 1st Street, Suite 800
Miami, FL 33131
Please complete the following accurately. Print clearly with black ink.
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 (please select one of the three options below)
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 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.
❑
I want to make post-tax (Roth 401(k)) salary deferral contributions to the Plan. I authorize my employer to
deduct $__________ or __________.0% of my 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 post-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: ___________________________