Governmental 457(b) Plan Massachusetts Deferred Compensation

Participant Enrollment
Governmental 457(b) Plan
Massachusetts Deferred Compensation SMART Plan 98966-01
Participant Participant
Participant Information Enrollment
Enrollment
Governmental Governmental 457(b) 457(b) Plan
Plan
Last Name First Name MI Social Security Number
Massachusetts Massachusetts Deferred Deferred Compensation Compensation SMART SMART Plan Plan - Mandatory OBRA 98966-02 98966-01 98966-02
Participant Participant
Information
Information Address - Number & Street E-Mail Address
Participant Enrollment
❑ Married ❑ Unmarried ❑ Female ❑ Male
Governmental Last Name First Name MI Social Security Number
Last Name 457(b) City Plan
State First Name Zip CodeMI Mo Day Year Social Security Number Mo Day Year
| | | |
Massachusetts ( ) Deferred Address Compensation - Number & ( Street SMART ) Plan - Mandatory OBRADate of Birth E-Mail Address Date of Hire98966-02
Address - Number & Street E-Mail Address
Home Phone Work Phone
❑ Married ❑ Unmarried ❑ Female ❑ Male
Participant Information
❑ Married ❑ Unmarried ❑ Female ❑ Male
City State Zip Code Mo Day Year Mo Day Year
Payroll Information City State Zip Code Mo Day Year Mo Day Year
| | | |
❑ ( I elect ) to Last contribute Name % or ( $ First
) Name (per MI | |
pay period) of my Date compensation of Birth Social as Security before-tax Number | |
Date contributions of Hire to the
(
Governmental
)
Home Phone 457(b) Deferred Compensation
(
Plan
)
until Work such Phone time as I revoke or amend my election.
Date of Birth Date of Hire
Home Phone Work Phone
Home Phone Work Phone
Payroll Address Effective - Number Date: & Street | |
E-Mail Address
Payroll Information
Mo Day Year
Investment
Investment
Option
Option
Information
Information
(applies
(applies
to
to
all
all
contributions)
contributions)
- Please
Please
refer
refer
to
to ❑ your
your Married marketing
marketing ❑ Unmarried communication
communication❑materials materials Female for
for❑information information Male
regarding
regarding
❑ I elect each
each
toinvestment investment option.
contribute City option. % or $ State To be completed Zip Code by
(per pay period) of Mo my Day compensation Year as before-tax Mo contributions Day Year to the
Governmental 457(b) Deferred Compensation Plan until such time as I revoke or amend my election.
I understand
understand
that
that
funds
funds
may
may
impose
impose
redemption
redemption
fees
fees
on
on
certain
certain Representative: transfers,
transfers,
redemptions
redemptions
or
or
exchanges
exchanges |
if
if
assets
assets |
are
are
held
held
less
less
than
than
the
the |
period
period |
stated
stated
in
in
the
the
fund’s
fund’s (
prospectus
prospectus )
or
or
Division other
other Payroll disclosure
disclosure
NameEffective
documents.
documents. Date: (
I will
will
refer
refer ) | to
to
the
the
fund’s
fund’s | prospectus
prospectus
Division and/or
and/or
Number disclosure
disclosure Date
documents
documents of Birth
for
for
more
more
information.
information. Date of Hire
Home Phone INVESTMENT Mo Work DayPhone Year
INVESTMENT OPTION NAME
OPTION
INVESTMENT
CODE
INVESTMENT OPTION NAME
OPTION CODE
The Investment Income Fund Option ........................................................ Information (applies (appliesMELINC to all To contributions) be completed % by - Please refer to your marketing communication materials for information
The regarding Income each Fund investment ........................................................ option.
MELINC Representative: %
MUST
MUST INDICATE
I understand that funds
Division
WHOLE
may
Name
PERCENTAGES =100%
impose redemption fees on certain transfers, redemptions
Division
or
Number
I understand
INDICATE
that funds
WHOLE
may impose
PERCENTAGES
redemption fees on certain
=100%
transfers, redemptions or exchanges if assets are held less than the period stated in the
Plan fund’s Beneficiary prospectus or Designation
other disclosure documents. I will refer to the fund’s prospectus and/or disclosure documents for more information.
Plan Beneficiary Designation
This Investment designation Option is effective Information upon execution (applies INVESTMENT
to all contributions) - Please refer to your marketing communication INVESTMENT materials for information
This
and delivery to Service Provider at the address below. I have the right to change the beneficiary. If any
INVESTMENT
information INVESTMENT regarding designation each is missing,
OPTION investment is effective
additional
NAME option. upon execution
information OPTION and delivery
may be CODE
to Service Provider INVESTMENT at the address OPTION below. NAME I have the right to OPTION change CODE the beneficiary. If any
information is missing, additional information may be required
required
prior
prior
to
to
recording
recording
my
my
beneficiary
beneficiary
designation.
designation.
If
If
my
my
primary
primary
and
and
contingent
contingent
beneficiaries
beneficiaries
predecease The predecease SMARTPath I understand Income me Fund me 2000 that or
or ........................................................ Retirement I funds fail
fail
to
to
may designate
designate Fund impose ........................... beneficiaries,
beneficiaries,
redemption MELINC SMPT00 fees amounts
amounts
on certain will
will 100
be
be
transfers, %
paid
paid
pursuant
pursuant
redemptions State to
to Street the
the
terms
terms Russ or exchanges 2000 of
of
the
the Ind Plan
Plan Sec if assets Lnd Document
Document Ser are A .................. held or
or
applicable
applicable
less SVR2IS than state the
state
period law.
law.
stated % in the
SMARTPath fund’s prospectus 2005 Retirement or other disclosure Fund ........................... documents. SMPT05 I will refer to the % fund’s prospectus Fidelity Fund and/or ............................................................... disclosure documents for more information.
FFIDX %
You
You MUST may
may INDICATE only
only
designate
designate WHOLE one
one
primary PERCENTAGES primary
and
and
one
one
contingent
contingent =100% beneficiary
beneficiary
on
on
this
this
form.
form.
However,
However,
the
the
number
number
of
of
primary
primary
or
or
contingent
contingent
beneficiaries
beneficiaries
SMARTPath 2010 Retirement Fund ...........................
INVESTMENT
SMPT10 % Eaton Vance Large Cap Value Eq Com Tr .................
INVESTMENT
ETCLCV %
you
you
name
name
is
is
not
not
limited.
limited.
If
If
you
you
wish
wish
to
to
designate
designate
more
more
than
than
one
one
primary
primary
and/or
and/or
contingent
contingent
beneficiary,
beneficiary,
do
do
not
not
complete
complete
the
the
section
section
below.
below.
Instead, INVESTMENT Instead, Plan SMARTPath Beneficiary complete
complete 2015 OPTION Retirement and
and Designation forward
forward NAME Fund ........................... the
the
Beneficiary
Beneficiary OPTION SMPT15 Designation
Designation CODE form.
form. % INVESTMENT KLD 400 Social OPTION Index Series NAME Fund ............................ OPTION KLD400 CODE %
Primary SMARTPath
SMARTPath Beneficiary 2000
2020
Retirement
Retirement
Fund
Fund
...........................
...........................
SMPT00
SMPT20
%
State
State
Street
Street
Russ
S&P 500
2000
Flagship
Ind Sec
Series
Lnd Ser
A .....................
A .................. SVR2IS
SV500
%
Primary This designation Beneficiary is effective upon execution and delivery to Service Provider at the address below. I have the right to change the beneficiary. If any
information SMARTPath
SMARTPath
100.00% 2005
2025 is missing, Retirement
Retirement additional Fund
Fund
...........................
........................... information may SMPT05
SMPT25 be required prior % to recording Fidelity
Fidelity my Fund
Growth beneficiary ...............................................................
Company designation. Fund ................................. If my primary FFIDX
FD-GRO and contingent beneficiaries
%
% predecease SMARTPath
SMARTPath 100.00%
of Account me 2010
2030 Balance or Retirement
Retirement I fail to designate Fund
Fund
...........................
........................... beneficiaries, Social Security SMPT10
SMPT30 amounts Number will be % Primary paid pursuant Beneficiary Eaton
T Rowe to Vance the Price Name terms Large
Structured of Cap the Value
Research Plan Eq Document Com
Comm
Tr .................
Tr ............. or Relationship applicable ETCLCV
TRSRCT state law. Date % of Birth
%
SMARTPath
SMARTPath
of Account
2015
2035
Balance
Retirement
Retirement
Fund
Fund
...........................
...........................
Social Security
SMPT15
SMPT35
Number
%
Primary Beneficiary
KLD
State Street
Name
400 Social
Pass
Index
Tr Infl
Series
Pt Sc
Fund
Ind NL
............................
A .....................
Relationship
KLD400
SVPTIP
Date
%
of Birth
Contingent You may only Beneficiary designate one primary and one contingent beneficiary on this form. However, the number of primary or contingent beneficiaries
Contingent you SMARTPath
SMARTPath name is 2020
2040 Beneficiary not Retirement
Retirement limited. Fund
Fund If you ...........................
........................... wish to designate SMPT20
SMPT40 more than % one primary State
PIMCO
Street and/or High
S&P
Yield contingent 500
Fund
Flagship
- Institutional beneficiary, Series A .....................
..................... do not complete SV500
PHIYX the section % below.
Instead,
SMARTPath
SMARTPath 100.00%
100.00% complete
2025
2045
Retirement
Retirement and forward
Fund
Fund
...........................
........................... the Beneficiary
SMPT25
SMPT45 Designation form.
%
Fidelity
PIMCO
Growth
Total Return
Company
- Inst.
Fund
........................................
................................. FD-GRO
PTTRX
%
%
SMARTPath
SMARTPath
of Account
2030
2050
Balance
Retirement
Retirement
Fund
Fund
...........................
...........................
Social Security
SMPT30
SMPT50
Number
%
Contingent Beneficiary
T
State
Rowe
Street
Name
Price
Pass
Structured
Bd Mkt
Research
Ind Sec Lnd
Comm
A ....................
Relationship
Tr ............. TRSRCT
SVPBMI
Date
%
of Birth
% Primary of Account Beneficiary Balance Social Security Number Contingent Beneficiary Name Relationship Date of Birth
SMARTPath
State Street Daily
2035
EAFE
Retirement
Sec Lnd
Fund
Series
...........................
T .................
SMPT35
SVEAFT
%
State
The Income
Street Pass
Fund
Tr
........................................................
Infl Pt Sc Ind NL A ..................... SVPTIP
MELINC
%
Participation 100.00%
Participation
Agreement
SMARTPath
INVESCO Equity Agreement
2040
Real
Retirement
Estate Sec
Fund
Tr
...........................
Cl MA .............
SMPT40
IVERES
%
PIMCO
Vanguard
High
Reserve
Yield
Prime
Fund
Money
- Institutional
Market
.....................
Inst ............
PHIYX
VMRXX
%
% of Account Balance Social Security Number Primary Beneficiary Name Relationship Date of Birth
Withdrawal SMARTPath
Active Withdrawal Small
2045
Cap Restrictions
Restrictions Stock
Retirement
Portfolio - I
Fund I understand ............................... understand that the
........................... that the SMPT45
WELASC Internal
Internal
Revenue
Revenue
% Code
Code
(the
(the "Code") and/or my employer’s Plan Document may impose restrictions on
transfers and/or distributions. I understand that I must contact the Plan Administrator/Trustee
MUST PIMCO "Code") Total INDICATE and/or Return my
to - WHOLE
determine Inst. employer’s ........................................ PERCENTAGES Plan Document
when and/or under PTTRX may impose
what circumstances
=100% restrictions % on
transfers
Contingent I am
SMARTPath and/or
Beneficiary
eligible to receive 2050 distributions. Retirement distributions Fund I understand
or ........................... that
make transfers. SMPT50 I must contact the % Plan Administrator/Trustee State Street Pass Bd to Mkt determine Ind Sec Lnd when A .................... and/or under SVPBMI what circumstances % I am
eligible
State Street
100.00% to receive distributions or make transfers.
Daily EAFE Sec Lnd Series T ................. SVEAFT % The Income Fund ........................................................ MELINC %
Compliance
Compliance % of Account Balance With Plan Document and/or Social the Security Code Number - Participation Contingent in this Plan Beneficiary is mandatory. Name A deduction will be taken Relationship from your wagesDate andof invested Birth
on INVESCO your behalf Equity With
based Real Plan Estate Document
on your Sec Tr employer’s Cl and/or MA ............. the
Plan IVERES Code - Participation
Document. I agree % in this Plan
that my Vanguard is mandatory.
employer Reserve or Plan Prime A deduction
Administrator/Trustee Money Market will be Inst taken ............ from
may take VMRXX your wages and
any action that % invested
on your behalf based on your employer’s Plan Document. I agree that my employer or Plan Administrator/Trustee may take any action that may
may
be
be
necessary Active Participation Small to Cap ensure Agreement
Stock that Portfolio my ............................... participation in the WELASC Plan is in compliance %
necessary to ensure that my participation in the Plan is in compliance with
with MUST any
any INDICATE applicable
applicable
requirement
requirement WHOLE PERCENTAGES of
of
the
the
Plan
Plan
Document
Document
and/or
and/or =100% the
the
Code.
Code.
I
understand
understand that the maximum annual limit on contributions is determined under the Plan Document and/or the Code. I understand that it is my
responsibility Withdrawal
that
Restrictions
the maximum
to monitor my - Itotal understand
annual limit
annual that
on
contributions the
contributions
Internal to ensure Revenue
is determined
that Code I do (the
under
not "Code")
the
exceed the and/or
Plan
amount my
Document
employer’s
and/or
permitted. If Plan
the
I exceed Document
Code. I
the contribution may
understand
impose
that
limit, restrictions
it is my
I assume on
responsibility
sole transfers liability and/or
to
for distributions.
monitor my total
any tax, penalty, I understand
annual contributions
or costs that may I must
to
be incurred. contact
ensure
the
that
Plan
I do
Administrator/Trustee
not exceed the amount
to determine
permitted.
when
If I exceed
and/or
the
under
contribution
what circumstances
limit, I assume
I am
sole
eligible
liability
to receive
for any
distributions
tax, penalty,
or
or
make
costs
transfers.
that may be incurred.
Incomplete
Incomplete Forms - I understand that in the event my Participant Enrollment form is incomplete or is not received by Service Provider at the address
Compliance
Forms
below prior to With the Plan
- I understand
receipt Document
that
of any deposits, and/or
in the
the
event
I specifically Code
my
- Participation
Participant Enrollment
consent to inService this Plan
form
Provider is mandatory.
is incomplete
retaining Aall deduction
or is not
monies will
received
received be taken
by Service
and from allocating your
Provider
them wages
at
to and
the
the invested
address
below
default
investment on your
prior
behalf
to the
option based
receipt
on your
of any
employer’s
deposits,
Plan
I specifically
Document.
consent
I agree
to
that
Service
my employer
Provider retaining
or Plan Administrator/Trustee
all monies received and
may
allocating
take any
them
action
to
that
the
may
default
be
investment
necessary to
option
ensure that my participation in the Plan is in compliance with any applicable requirement of the Plan Document and/or the Code. I
Account
Account
understand Corrections
Corrections
that the maximum - I understand
understand
annual that
that
limit it
it
is
is
on my
my
contributions obligation
obligation
to
to
is review
review
determined all
all
confirmations
confirmations
under the and
and
Plan quarterly
quarterly
Document statements
statements
and/or for the
for
discrepancies
discrepancies
Code. I understand or
or
errors.
errors.
that Corrections
Corrections
it is my
will
will
responsibility be
be
made
made
only
only
to monitor for
for
errors
errors
my which
which
total annual I communicate
communicate
contributions within
within
to ensure 90
90
calendar
calendar
that I days
days
do not of
of
the exceed
the
last
last
the calendar
calendar
amount quarter.
quarter.
permitted. After
After
If this
this
I exceed 90
90
days,
days,
the account
account
contribution information
information
limit, I shall
shall
assume be
be
deemed
deemed
sole liability accurate
accurate
for any and
and
tax, acceptable
acceptable
penalty, to
to
or me.
me.
costs If
If
I that notify
notify
may Service
Service
be incurred. Provider
Provider
of
of
an
an
error
error
after
after
this
this
90
90
days,
days,
the
the
correction
correction
will
will
only
only
be
be
processed
processed
from
from
the
the
date
date
of
of
notification
notification forward and not on a retroactive basis.
Incomplete
forward
Forms -
and
I understand
not on a retroactive
that in the
basis.
event my Participant Enrollment form is incomplete or is not received by Service Provider at the address
below prior to the receipt of any deposits, I specifically consent to Service Provider retaining all monies received and allocating them to the default
investment option
][Form 1 ][GWRS FENRAP ][01/31/08 ][Page 1 of 3
][ADMIN FORMAT
Account ][TAYO][/151014421 Corrections - I understand that it is my obligation to review all confirmations and quarterly statements for discrepancies or errors. D02:120507 Corrections
will be made only for errors which I communicate within 90 calendar days of the last calendar quarter. After this 90 days, account information shall be
deemed accurate and acceptable to me. If I notify Service Provider of an error after this 90 days, the correction will only be processed from the date of
notification forward and not on a retroactive basis.
][Form ][Form
1 1
][GWRS ][GWRS
FENRAP FENRAP
3121
3121 ][01/31/08 ][01/31/08
][01/31/08 ][Page ][Page
][Page 1 of 31
1
of
of
2
][ADMIN ][ADMIN
FORMAT
FORMAT
][TAYO][/151014421
][TAYO][/151014429
][TAYO][/151014429
D02:120507
D02:120507

Last Name First Name MI Social Security Number
Required Signatures - I have completed, understand and agree to all pages of this Participant Enrollment form. I understand that Service Provider is
required to comply with the regulations and requirements of the Office of Foreign Assets Control, Department of the Treasury ("OFAC"). As a result,
Service Provider cannot conduct business with persons in a blocked country or any person designated by OFAC as a specially designated national or
blocked person. For more information, please access the OFAC Web site at: http://www.ustreas.gov/offices/eotffc/ofac. Deferral agreements must be
entered into prior to the first day of the month that the deferral will be made.
Participant Signature Date
Registered Representative Signature and ID Date
Participant forward to Service Provider at:
Great-West Retirement Services®
PO Box 173764
Denver, CO 80217-3764
Express Address:
8515 E. Orchard Road, Greenwood Village, CO 80111
Phone #: 1-877-457-1900
Fax #: 1-866-745-5766
][Form 1 ][GWRS FENRAP 3121 ][01/31/08 ][Page 2 of 2
][TAYO][/151014429
][ADMIN FORMAT
D02:120507