QMS Enrollment - Web Book - Ready - Flipbook - Page 19
QUALITY MANUFACTURING SERVICES 401(K) PLAN
Enrollment / Information Change Form
Certified Benefits Corp
1111 Douglas Avenue
Altamonte Springs, FL 32714
Quality Manufacturing Services, Inc.
400 Rinehart Road, Suite 1010
Lake Mary, FL 32746
Please complete the following accurately. Print clearly.
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
❑
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 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: ___________________________
