NPERS8400
Rev. 11/2019
Page 1 of 1
BAR CODE
Name
LAST FIRST MIDDLE
Date of Birth
OFFICE USE
ONLY
Email
Initials _______
Date ________
Fhdr ________
Address City State Zip
Home Phone
Work Phone
Employer
INVESTMENT ELECTION (FUTURE ONLY)
Make your selection(s) in whole increments totaling 100%. Elections will only change future contributions. See transfer section below for transfer
of existing balances. Funds are not guaranteed as to rate of return or principal stability. Your employer is held harmless against any losses.
% Stable Value (10)
% Conservative Premixed (21)
% S & P 500 Stock Index (15)
% Small Company Stock (16)
% Money Market (13)
% Moderate Premixed (23)
% Lg. Co. Gro. Stock Index (19)
% International Stock (17)
% Bond Market Index (18)
% Aggressive Premixed (22)
% Lg. Co. Value Stock Index (20)
% Investor Select (24)
% Age-Based: Age 0-39 (26)
% Age-Based: Age 40-59 (27)
% Age-Based: Age 60 & Up (25)
TRANSFER OF EXISTING BALANCES/ELECTED DEFERRALS
A transfer will move a dollar amount or % of your existing funds from one investment fund to another. A transfer between the Stable Value
Fund and the Money Market Fund, which is a “competing fund,” is not allowed.
TRANSFER $
OR
% from the
FUND, into the
FUND.
TRANSFER $
OR
% from the
FUND, into the
FUND.
TRANSFER $
OR
% from the
FUND, into the
FUND.
TRANSFER $
OR
% from the
FUND, into the
FUND.
TRANSFER $
OR
% from the
FUND, into the
FUND.
TRANSFER $
OR
% from the
FUND, into the
FUND.
If making contribution changes or deferring sick/vacation leave, please submit this form to your payroll department.
They will forward the form to NPERS and set up the payroll deduction. If you are only making changes to investment elections or transfers, you may
submit directly to NPERS. Changes to investment elections/ transfers will be processed within 3 business days of receipt. Changes to contribution
amounts will be made the month following receipt of this form. For vacation and sick leave payments for terminating employees, this form must be
submitted the calendar month prior to the month of termination.
Member
Signature:
Date:
AGENCY ACTION: Please review
this form and the instructions above
(for deadlines). You will be notified
when the member has been
enrolled and deductions may begin.
Agency
Signature:
Agency
Number:
Deferred Compensation Plan (DCP) Change Form
COMPLETE ONLY THOSE SECTIONS BELOW THAT APPLY TO CHANGES YOU WISH TO MAKE.
CONTRIBUTION CHANGE
Contributions to the plan are pre-tax deductions from your pay. The maximum amount that may be contributed each year is the lesser of
(a) 100% of your annual compensation less contributions to retirement plans OR (b):
YEAR
NORMAL LIMITATION DEFERRAL
+
AGE 50 ADDITIONAL CATCH-
UP
=
AGE 50 MAXIMUM
DEFERRAL
2020
$19,500
$6,500
$26,000
You will be notified if contributions designated on this form are expected to exceed IRS limitations. If you are 50 or older
you may contribute up to the Age 50 Maximum Deferral.
Contribution Per Pay Period: $_____________
FREQUENCY:
Monthly = 12 per year Bi-Weekly = 24 per year
Start date:
As soon as possible.
(No sooner than the month following the month the form is submitted.)
After paycheck dated: __________/__________/____________
Estimated Annual Salary: $________________ Have you contributed to another 457 plan this calendar year? Yes No
(If yes, please attach a copy of your statement from the other 457 plan.)
I wish to defer from final sick/vacation leave pay. Termination Date: ________/________/_________
0
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