Fill and Sign the Enrollment and Salary Deferral Agreement Form

_________________________________ (Insert Name of Plan Here) Enrollment and Salary Deferral Agreement Participant’s Name : Date : ___________ Address : Date of Birth : _____________ Date of Hire : ______ Social Security Number: Daytime Phone Number__________________ E-Mail Address____________________ [ ] I hereby elect to become a Participant in the 401(k) Plan on _________________ (date). As a Participant, I hereby authorize the Employer to deduct ____% of my Compensation or a flat dollar amount of $___________ (per payroll period), which I understand will be contributed by the Employer to the Plan for allocation to my account on a pre-tax 401(k) basis. As a Participant, I hereby authorize the Employer to deduct _____________% of my Compensation or a flat dollar amount of $___________ (per payroll period), which I understand will be contributed by the Employer to the Plan for allocation to my account on an after-tax Roth 401(k) basis. The total combined contributions may not exceed the Code Section 402(g) $15,500 limit, as indexed plus catch-up contributions if I am 50 or older. The Employer may also limit the maximum combined percentage limit of regular 401(k) and Roth 401(k) contributions. [ ] Catch-Up Election As a Participant, I certify that I am eligible ( i.e. I will be age 50 or older by the end of the calendar year) to make Catch-up Contributions to the Plan. I hereby authorize the Employer to deduct an additional _____% or a flat dollar amount of $____________, of my Compensation which I understand will be contributed by the Employer to the Plan for allocation to my account on a pre-tax 401(k) basis. I also understand that this amount may not be deemed a Catch-up Contribution until the last day of the Plan Year and may be disallowed in which case the disallowed contribution will be returned to me and become taxable income (unless the Plan permits Voluntary After-tax Contributions). As a Participant, I certify that I am eligible ( i.e. I will be age 50 or older by the end of the calendar year) to make Catch-up Contributions to the Plan. I hereby authorize the Employer to deduct an additional _____% or a flat dollar amount of $___________, of my Compensation which I understand will be contributed by the Employer to the Plan for allocation to my account on an after-tax Roth 401(k) basis. I also understand that this amount may not be deemed a Catch-up Contribution until the last day of the Plan Year and may be disallowed in which case it will be returned to me. [ ] I do not wish to make contributions to the Plan at this time. I understand that the elections I have made above will remain in effect, until I notify the Employer otherwise. Investment Direction (If Individual Directed Accounts are Permitted) If individual investments are permitted, you must complete a separate investment direction form as provided by the Investment Firm. You may also manage your account on line. Please set this up once deferrals have begun. Your deferral election/change will begin as of the next payroll period or as soon as administratively possible: Please provide updated address information immediately if this information changes. ______________________________________ Participant’s Signature Date: __________________ Received by Plan Administrator: _______________ Date: _________________