For Office Use Only: Participant: New_______ Update_________ _ __ Contribution: Increase_____ Decrease_____ _ __ Allocation Change: Current_____ Future___ _ ___
Participant Enrollment/ Investment Election Form ESSDACK Consortium 403(b) Retirement Plan
PARTICIPANT INFORMATION (Please Print Information Clearly)
Date of Birth:
Full Name: Street: Social Security #: Date of Hire: Home Email Address: Electronic Statements Only:
City:
State:
Zip:
Phone:
Marital Status:
Married
Single
Divorced
School District:
Work Email Address:
Yes
No
CONTRIBUTION ELECTION: Elective Deferrals (combined annual maximum of $ 2 3 , 5 00 annually/ $1, 9 58 . 33 monthly) I elect to participate and contribute $ ☐ or % of compensation per pay period on a pre-tax basis ($ 2 3 , 5 00 max)
I elect to participate and contribute $ ($ 2 3 , 5 00 max)
or
% of compensation per pay period on a Roth basis
☐
☐ I elect not to make deferrals until I indicate otherwise. I understand that if I do not participate now, or I discontinue participation, I will not be allowed to begin deferrals until the next available enrollment date.
Catch- Up Contributions: If you will be at least 50 years old as of December 31st of the current year, and you contribute the maximum to the plan, you are entitled to make an additional "catch-up" contribution of up to $ 7 , 5 00 under current law. Under a change made in SECURE 2.0, a higher catch-up contribution limit applies for employees aged 60, 61, 62 and 63 who participate in these plans. For 2025, this higher catch-up contribution limit is $11,250 instead of $7,500.
SIGNATURES:
Participant Signature:
Date:
Date:
Plan Sponsor Signature:
For more information about your plan, you can call (8 77 ) 410 - 9984 (ext 4015) , or access the internet site at https://www.yourbenefitaccount.net/yourfutureisdaily/
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