"Salary Reduction Agreement - Beneficiary Designation Form - Adventist Retirement Plan - Seventh-Day Adventist Church"

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Adventist Retirement P
Salary Reduction Agreement
Beneficiary Designation Form
Plan ID# 69472001
New Enrollment
Beneficiary Change
Deferral Change
Name:
_______________________________________ SSN:__________________
Address:
______________________________________________________________
City:
____________________
State: ________
ZIP: _________________
Voluntary Contributions
I wish to make employee pre-tax contributions to my ARP account from my eligible salary every pay period:
_____% (Preferred) or $______
and/or,
I wish to make employee Roth 403(b) after-tax contributions to my ARP account from my eligible salary every
pay period (Not all employers provide the Roth 403(b) option): _____% (Preferred) or $______
and/or
I wish to make non-deductible after-tax contributions (non-Roth 403(b) to my ARP account from my eligible
salary every pay period:
_____% (Preferred) or $______
Beneficiary Designation (complete only if you are enrolling or changing your beneficiary)
If married, you may only designate your spouse as Primary Beneficiary on this form. To name more than one beneficiary
or to name someone other than your spouse, you must complete an Alternative Beneficiary Designation Form.
Primary Beneficiary
Contingent Beneficiary
Name:
_________________________
___________________________
SSN:
_________________________
___________________________
Relationship:
_________________________
___________________________
Address:
_________________________
___________________________
City:
_________________________
___________________________
State/Zip:
__________ / _____________
__________ / _______________
Date of Birth
________________________
___________________________
Employee Signature (please select one paragraph below)
I DO NOT WISH to participate in a salary reduction agreement with ARP at this time. I understand that by not
participating I will be ineligible for the employer matching contribution. I further understand that I may elect to
participate in the Plan in the future, and it is my responsibility to contact the Human Resources Department through my
employer to do so.
I agree that my employer may reduce my salary by the percentage or amount which I have elected to contribute
to my ARP account. I understand that ARP may limit my contributions in order to comply with federal law and the Plan
document. I understand that if my contribution rate is less than 3%, I may not receive the maximum employer match.
Employee Signature
Date
Return This Form to Your Local Payroll Office
Questions about this form may be directed to 1-800-448-2542, Monday through Friday, 8:00 a.m. to 6:00 p.m. Eastern
11/2009
lan
Adventist Retirement P
Salary Reduction Agreement
Beneficiary Designation Form
Plan ID# 69472001
New Enrollment
Beneficiary Change
Deferral Change
Name:
_______________________________________ SSN:__________________
Address:
______________________________________________________________
City:
____________________
State: ________
ZIP: _________________
Voluntary Contributions
I wish to make employee pre-tax contributions to my ARP account from my eligible salary every pay period:
_____% (Preferred) or $______
and/or,
I wish to make employee Roth 403(b) after-tax contributions to my ARP account from my eligible salary every
pay period (Not all employers provide the Roth 403(b) option): _____% (Preferred) or $______
and/or
I wish to make non-deductible after-tax contributions (non-Roth 403(b) to my ARP account from my eligible
salary every pay period:
_____% (Preferred) or $______
Beneficiary Designation (complete only if you are enrolling or changing your beneficiary)
If married, you may only designate your spouse as Primary Beneficiary on this form. To name more than one beneficiary
or to name someone other than your spouse, you must complete an Alternative Beneficiary Designation Form.
Primary Beneficiary
Contingent Beneficiary
Name:
_________________________
___________________________
SSN:
_________________________
___________________________
Relationship:
_________________________
___________________________
Address:
_________________________
___________________________
City:
_________________________
___________________________
State/Zip:
__________ / _____________
__________ / _______________
Date of Birth
________________________
___________________________
Employee Signature (please select one paragraph below)
I DO NOT WISH to participate in a salary reduction agreement with ARP at this time. I understand that by not
participating I will be ineligible for the employer matching contribution. I further understand that I may elect to
participate in the Plan in the future, and it is my responsibility to contact the Human Resources Department through my
employer to do so.
I agree that my employer may reduce my salary by the percentage or amount which I have elected to contribute
to my ARP account. I understand that ARP may limit my contributions in order to comply with federal law and the Plan
document. I understand that if my contribution rate is less than 3%, I may not receive the maximum employer match.
Employee Signature
Date
Return This Form to Your Local Payroll Office
Questions about this form may be directed to 1-800-448-2542, Monday through Friday, 8:00 a.m. to 6:00 p.m. Eastern
11/2009