457 DEFERRED COMPENSATION PLANS
CONTRIBUTION FORM
1
PARTICIPANT INFORMATION
3
SIGNATURES
Participant Signature
Date: / /
Employer Signature
Date: / /
ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org/cityofoakland • Fax 202-682-6439
FRM570-40816 0119-C3015
2
CONTRIBUTION AMOUNT & EFFECTIVE DATE
Contribution Amount (per pay period)
I authorize my employer to contribute the amount specied 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)
Percentage election is a percentage of your gross pay.
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 per year) Enter dollar amount $ _____________________. (per pay period)
Special pre-retirement catch-up (up to $19,000 more than the normal limit. $38,000 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 specied 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 employer’s plan.
2. Return the completed form to your employer.
Year Maximum Contribution Age-50 Catch-Up Pre-Retirement Catch-Up
2019
19,000
(Approximately $731 every two weeks)
$6,000
($25,000 total)
$19,000
($38,000 total)
Identication (Please provide your Social Security Number or Employee ID)
Social Security Number: – –
OR Employee ID: _____________________________________
Employer Plan Number: 307108 Employer Plan Name: City of Oakland
Full Name of Participant: _________________________________________________ Department: ______________________________
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