Employee Pension Contributions

EMPLOYEE PENSION CONTRIBUTIONS

Personal Information

Position and Employer Information

Effective date for this election:    Employee ID number:

Contribution Election

I elect to contribute (select all that apply):

Investment Allocation

Allocate contributions among available plan investment options. Enter percentages that total 100%. If left blank, contributions will be invested in the plan default fund.

Beneficiary Designation

Primary beneficiary(ies):

Contingent beneficiary(ies):

Employer Match & Vesting Acknowledgement

By signing below, I acknowledge that employer matching contributions, if any, will be made in accordance with the terms of the employer's pension plan and the applicable vesting schedule. Employer contributions are plan assets subject to plan provisions, limitations, and restrictions.

Payroll Deduction Authorization

I authorize my employer to deduct the contribution amounts elected above from my wages and to apply those amounts to the pension plan on my behalf. I understand that this election will remain in effect until I submit a written change or revocation in accordance with plan procedures.

Legal Notices and Acknowledgements

I acknowledge that contributions are subject to the terms of the employer's pension plan document and summary plan description. Contributions are subject to plan limits, tax treatment under applicable law, and may be amended or suspended by the employer in accordance with plan procedures. Neither this form nor any statement by any employer representative alters the written terms of the plan.

I understand that salary deferrals reduce my taxable income to the extent provided by law and that Roth contributions are made with after-tax dollars and may have different tax consequences. I agree to consult a tax advisor for guidance on tax consequences.

At-Will Employment and Equal Opportunity

This contribution election is separate from employment status. Employment remains at-will and may be terminated by either party at any time, unless otherwise provided by a written agreement signed by authorized representatives. The employer is an equal opportunity employer and does not discriminate in benefits administration on any protected basis.

Applicant Certification and Authorizations

I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize the employer and plan administrator to process my elections, to verify any information provided, and to contact previous employers or other references as necessary to administer plan benefits. I authorize any person or entity to release information necessary to verify facts provided on this form or to administer eligibility and contributions.

Employment History (most recent)

Education

Professional References

Provide three professional references who can verify your employment or qualifications.

Authorization to Contact and Background Check

I authorize the employer, plan administrator, and third-party administrators to contact prior employers and references for the purpose of verifying employment history and eligibility for plan participation. I also consent to any background or eligibility checks required by plan administration.

Employee Statement and Signature

By signing below I confirm that I have read and understand this contribution election, that I have authority to make this election, and that I accept responsibility for monitoring my elections with respect to plan limits and tax consequences. I understand that this form does not constitute a promise of employment or modify the terms of my employment relationship.

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