360 North Main Street • Logan, Utah 84321
Telephone: 435-752-8484 • Toll-free: 800-327-5400 • Fax: 435-752-8487
This form is used to enroll in or
make changes to a 457 plan account
administered by Harold Dance
Investments.
For questions regarding this form, to
request a different form, or to
discuss other aspects of the 457
plan, please contact Harold Dance
Investments.
Phone:
435-752-8484
Toll Free:
800-327-5400
457 Application & Change Form
New: [ ] Amended: [ ] Transfer: [ ] (check one)
AGREEMENT between (employer):_______________________________________
and (employee):_________________________________ T-Number:_____________
Home Phone:___________________________________ Birth Date:_____________
Work Phone:____________________________________ Male: [ ] Female: [ ]
Address:______________________________________________________________
City:____________________________ State:_________ Zip:___________________
Subject to the provisions of the Southern Utah University 457 Plan adopted by my
employer, as the same may be amended, I hereby request my employer to defer
payment of the sum of $________ or ____% per pay period from my salary which will
not exceed the amount allowed under Section 457(b) and (c) of the Code as amended
and a minimum deferral of $25 per pay period. Deductions to begin
____/____/________ and continue until I cancel or modify this contract. The
employer may only defer compensation that has not been earned.
Deferral Type
Traditional (pre-tax): [ ] Roth (after-tax): [ ]
(check one)
Investment Selection
$________ or ____% per pay period to _____________________________________
$________ or ____% per pay period to _____________________________________
$________ or ____% per pay period to _____________________________________
Beneficiary Designation
Name:_________________________________________ SSN:__________________
Relation:_______________________________________ Birth Date:_____________
Plan Information
The Employee understands that this is a 457 Deferred Compensation Plan subject to
the provisions of section 457 of the IRS code as amended. The Employee
acknowledges that all his or her rights under this Deferred Compensation Plan are
subject to the terms of this Plan, that this Plan does not constitute an employment
contract, that the Employee shall look solely to the assets in the Participation Account
for the amount of this deferred compensation, that the shares shall be registered in the
name of the Employer, and that the Employee, his or her heirs, successors, and assigns
shall hold the Employer harmless from any liability under this Plan for all acts
performed in good faith including acts relating to the investment of deferred amounts
and/or the Employee's investment selection.
Signatures
EMPLOYEE Signature:_______________________________Date:______________
EMPLOYER Signature:_______________________________Date:______________
Please return the completed form via
mail or fax.
Mail:
Harold Dance Investments
360 N. Main St.
Logan UT 84321
Fax:
435-752-8487
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