Form CMS-DC-274 State Employees' Deferred Compensation Plan - Change Form - Illinois

Form CMS-DC-274 is a Illinois Department of Central Management Services form also known as the "State Employees' Deferred Compensation Plan - Change Form". The latest edition of the form was released in July 1, 2015 and is available for digital filing.

Download a PDF version of the Form CMS-DC-274 down below or find it on Illinois Department of Central Management Services Forms website.

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STATE EMPLOYEES’
DEFERRED COMPENSATION PLAN
CHANGE FORM
Type or print clearly in ink. Initial any corrections, additions, deletions or changes in pen. Fill out your
Scan forms to:
CMS.Ben.DefComp@illinois.gov
name, social security number and payroll code number; complete additional information only if it
Fax: 217-782-7640 ~ Office: 217-782-7006
reflects a change. For more information, call the Deferred Compensation Office at 1-800/442-1300,
1-217/782-7006 or TDD 1-800/526-0844.
Last Name
First Name
Middle Initial
SSN
Street
City
State
ZIP Code
Birth Date
Agency or University
Work Phone
Home/Cell Phone
Work Address
Payroll Code # (see your pay stub)
SECTION A: DESIGNATE A PLAN -
A separate Change Form is required if you wish to make a contribution amount change in both the pre-tax
and Roth (after-tax) accounts.
Pre-tax Deferred Compensation
After-tax Roth
SECTION B: TRANSACTION TYPE -
Check Appropriate Box(es)
Change in Contribution Amount
Change of Mailing Address
Name Change (State Previous Below)
(Complete Section C
(Home)
Revocation
Change of Work Address
Transfer to New Agency
(Complete Section D)
(Effective Date)
(mm/dd/yyyy)
SECTION C: AMOUNT OF CONTRIBUTION -
The minimum amount of contribution is $10 per pay period or $20 per month, whichever is greater.
Indicate the amount to be deducted from each paycheck. Contribution changes can be effective no sooner than the first pay period of the next month.
I hereby elect to participate in the State Employees' Deferred Compensation Plan. I authorize the State of Illinois to deduct from my total
compensation, the amount stated below, each pay period until my termination, modification or revocation of this amount, beginning on the
pay period designated below:
Amount to be deducted each pay period:
First Pay Period
Second Pay Period
in
(mm/yy)
SECTION D: REVOCATION OF CONTRIBUTION
I hereby revoke my election to participate in the State Employees' Deferred Compensation Plan, effective the pay period beginning with the
choice below:
First Pay Period
Second Pay Period
in
(mm/yy)
READ THIS INFORMATION COMPLETELY BEFORE SIGNING
1. I am aware that the change in my contribution amount may be effective no sooner than the first pay period of the next month.
2. I am aware that my contributions will continue to be invested as previously instructed, and that if I wish to make an investment allocation
change I may do so by calling the Plan's record keeper (T. Rowe Price) at 1-888-457-5770.
3. I am aware that my revocation may be effective immediately following approval by the Department.
4. I am aware that any Name, Address, or Agency change will be effective upon approval of this form.
Signature X
Date
Send this completed form to your Agency Liaison - or send directly to the Department of Central Management Services.
Liaison
Approval of Deferred Compensation Office required
Name
Agency
before any transaction takes place.
Date
Phone Number
Date
By
In compliance with the State and Federal Constitution, the Illinois Human Rights Act, the Americans with Disabilities Act and Section 504 of the Federal Rehabilitation Act, the Department of
Central Management Services does not discriminate in employment, contracts, or any other activity.
Central Management Services requests disclosure of information that is necessary to establish its obligations, primarily the statutory purposes under the State Employee Group Insurance Act
(5 ILCS 375). Disclosure of the information requested on this form is mandatory, and failure to provide requested information may result in rejection of this form or delay in making a change of
address. Social Security numbers are used in the application process to properly identify members and their dependents, if any. Confidentiality of Social Security numbers obtained through this
change of address process will be preserved as prescribed by 5 ILCS 179 et seq.
CMS-DC-274 (Rev. 07/15)
IL 401-1571
IOCI 16-24
STATE EMPLOYEES’
DEFERRED COMPENSATION PLAN
CHANGE FORM
Type or print clearly in ink. Initial any corrections, additions, deletions or changes in pen. Fill out your
Scan forms to:
CMS.Ben.DefComp@illinois.gov
name, social security number and payroll code number; complete additional information only if it
Fax: 217-782-7640 ~ Office: 217-782-7006
reflects a change. For more information, call the Deferred Compensation Office at 1-800/442-1300,
1-217/782-7006 or TDD 1-800/526-0844.
Last Name
First Name
Middle Initial
SSN
Street
City
State
ZIP Code
Birth Date
Agency or University
Work Phone
Home/Cell Phone
Work Address
Payroll Code # (see your pay stub)
SECTION A: DESIGNATE A PLAN -
A separate Change Form is required if you wish to make a contribution amount change in both the pre-tax
and Roth (after-tax) accounts.
Pre-tax Deferred Compensation
After-tax Roth
SECTION B: TRANSACTION TYPE -
Check Appropriate Box(es)
Change in Contribution Amount
Change of Mailing Address
Name Change (State Previous Below)
(Complete Section C
(Home)
Revocation
Change of Work Address
Transfer to New Agency
(Complete Section D)
(Effective Date)
(mm/dd/yyyy)
SECTION C: AMOUNT OF CONTRIBUTION -
The minimum amount of contribution is $10 per pay period or $20 per month, whichever is greater.
Indicate the amount to be deducted from each paycheck. Contribution changes can be effective no sooner than the first pay period of the next month.
I hereby elect to participate in the State Employees' Deferred Compensation Plan. I authorize the State of Illinois to deduct from my total
compensation, the amount stated below, each pay period until my termination, modification or revocation of this amount, beginning on the
pay period designated below:
Amount to be deducted each pay period:
First Pay Period
Second Pay Period
in
(mm/yy)
SECTION D: REVOCATION OF CONTRIBUTION
I hereby revoke my election to participate in the State Employees' Deferred Compensation Plan, effective the pay period beginning with the
choice below:
First Pay Period
Second Pay Period
in
(mm/yy)
READ THIS INFORMATION COMPLETELY BEFORE SIGNING
1. I am aware that the change in my contribution amount may be effective no sooner than the first pay period of the next month.
2. I am aware that my contributions will continue to be invested as previously instructed, and that if I wish to make an investment allocation
change I may do so by calling the Plan's record keeper (T. Rowe Price) at 1-888-457-5770.
3. I am aware that my revocation may be effective immediately following approval by the Department.
4. I am aware that any Name, Address, or Agency change will be effective upon approval of this form.
Signature X
Date
Send this completed form to your Agency Liaison - or send directly to the Department of Central Management Services.
Liaison
Approval of Deferred Compensation Office required
Name
Agency
before any transaction takes place.
Date
Phone Number
Date
By
In compliance with the State and Federal Constitution, the Illinois Human Rights Act, the Americans with Disabilities Act and Section 504 of the Federal Rehabilitation Act, the Department of
Central Management Services does not discriminate in employment, contracts, or any other activity.
Central Management Services requests disclosure of information that is necessary to establish its obligations, primarily the statutory purposes under the State Employee Group Insurance Act
(5 ILCS 375). Disclosure of the information requested on this form is mandatory, and failure to provide requested information may result in rejection of this form or delay in making a change of
address. Social Security numbers are used in the application process to properly identify members and their dependents, if any. Confidentiality of Social Security numbers obtained through this
change of address process will be preserved as prescribed by 5 ILCS 179 et seq.
CMS-DC-274 (Rev. 07/15)
IL 401-1571
IOCI 16-24
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