457 DEFERRED COMPENSATION PLANS
CONTRIBUTION FORM
1
PARTICIPANT INFORMATION
2
CONTRIBUTION AMOUNT & EFFECTIVE DATE
3
SIGNATURES
Participant Signature
Date:
/ /
Employer Signature
Date:
/ /
ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439
FRM570-1117-360
Contribution Amount (per pay period)
I authorize my employer to contribute the amount specied below from my pay each pay period, to be contributed to my 457 deferred compensation plan account with ICMA-RC. (Specify a
percentage or dollar amount for pre-tax and/or Roth contributions.)
Pre-Tax Contributions: Percentage: _______ % or Dollar Amount: $____________ (per pay period)
Roth Contributions: Percentage: _______ % or Dollar Amount: $____________ (per pay period)
Roth contributions are not available in all plans. Please check with your employer or ICMA-RC to conrm that Roth contributions are offered in your plan
before selecting this option.
Normal Contribution Limit (2018): 100% of compensation or $18,500, whichever is less.
Catch-up Contributions: If you are taking advantage of either of the catch-up contribution provisions available to 457 plan participants, please check the applicable box below.
Age 50 catch-up contributions (up to $6,000 more than the normal limit. $24,500 maximum.)
Special pre-retirement catch-up (up to $18,500 more than the normal limit. $37,000 maximum.)
Please read ICMA-RC’s Pre-Retirement Catch-Up Form for more information.
Effective Date
All contribution changes will be effective as of the rst pay period of the calendar month following the date you submit this form to your employer, or as soon as administratively possible
thereafter, unless a later date is specied below.
Future Effective Date (cannot be earlier than the beginning of the following month):
______
/
______
/
_________
1. Use this form to initiate contributions to your 457 deferred compensation plan or change the amount of your after-tax contributions.
Note: You should only use this form if you have previously established an account in your employers plan.
2. Return the completed form to your employer.
Year Maximum Contribution Age-50 Catch-Up Pre-Retirement Catch-Up
2018
18,500
(Approximately $711 every two weeks)
* If you are paid semi-monthly (24 pay periods per
year), contribute $770 per pay period.
$6,000
($24,500 total)
$18,500
($37,000 total)
Identication (Please provide your Social Security Number or Employee ID)
Social Security Number:
______
______
_________ OR Employee ID: _____________________________________
Employer Plan Number:
_________________
Employer Plan Name: _________________________________________________
Full Name of Participant: _____________________________________________________________________________________________
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