457 Enrollment/Change Form

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Newton Public Schools
Section 457 Deferred Compensation Plans
Employee Enrollment / Change Form
Employee Name:
Employee Number:
Employee Social Security #:
Date of Birth:
_______________________________________________________________________________________________________________________________________
Providers:
ICMA:
Mike Savage
Phone: 800-735-7202 ext. 4929; email: [email protected]
ING:
Ernest Krieger Phone: 781-796-9861; email: [email protected]
__________________________________________________________________________________________
1. ENROLLMENT: (new Members)
I authorize the City of Newton as my employer to defer $____________ of my pay per pay period into my
Section 457 Account(s). Deferrals should become effective on: __________________________
My 457 Plan is with:
ICMA:
ING:
__________________________________________________________________________________________
2. CHANGE 457 PLAN: (To change my provider, the amount of contributions, or to stop contributions)
I authorize the City of Newton to change provider From: ICMA:
ING:
To: ICMA:
ING:
I authorize the City of Newton to change the amount of my contributions From:
$
To:
$
I authorize the City of Newton to Stop all contributions to my 457 Plan
This change should become effective on: ___________________________
__________________________________________________________________________________________
3. CATCH-UP PROVISION:
I authorize the City of Newton as my employer to change my deferral of my pay into a “Traditional
Catch-up Deferral (Last 3 Years):”
ICMA:
$
ING:
$
I authorize the City of Newton as my employer to change my deferral of my pay into a “Age 50 Catch-up
Deferral:”
ICMA: $
ING:
$
__________________________________________________________________________________________
4. EMPLOYEE SIGNATURE:
Signature:
Date:
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