32717 CalSavers (Rev. 7/2021) 36466 ©2021 Ascensus, LLC
EMPLOYEE OPT OUT FORM
CalSavers is a completely voluntary program. You can opt out at any time online, by completing this form, or by calling the phone number
listed below. If you do not opt out your employer will send payroll contributions to your CalSavers account. Amounts you save in this account
are always your money. Your account is in your control and goes with you from job to job in accordance with the CalSavers Program terms.
Every little bit you save now can potentially make a difference in retirement. To opt out of payroll contributions to CalSavers for more than one
employer you must submit a separate form for each employer.
Completed forms should be mailed to: CalSavers Overnight Address: CalSavers
PO Box 55759 95 Wells Avenue, Suite 155
Boston, MA 02205-5759 Newton, MA 02459
855-650-6918
8:00 am to 8:00 pm Pacific Standard Time M-F saver.calsavers.com
1.
IDENTIFICATION (Required)
To verify your information, you must provide either your access code or the last four digits of your Social Security Number/Taxpayer
Identification Number, date of birth, and zip code. The access code can be found in the email or letter you received from CalSavers.
OR
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Access Code Last Four Digits of Social Zip Code Birth Date (mm/dd/yyyy)
Social Security Number or
Taxpayer Identification Number
2.
EMPLOYEE INFORMATION
Legal Name (First) (M.I.)
Legal Name (Last)
Address
— —
City State Telephone Number (In case we have a question)
3.
OPT OUT REASON
I don’t qualify for a Roth IRA due to my income
I don’t trust the financial markets
I would prefer a Traditional IRA
I’m not satisfied with the investment options
I have my own retirement plan
I’m not interested in contributing through this employer
I can’t afford to save at this time
Other
4.
EMPLOYER INFORMATION
Employer Name
5.
SIGNATURE (Required)
I do not wish to participate in the CalSavers Program at this time. I understand that I can change my mind at any time and begin participating in
CalSavers at a later date, subject to and in accordance with the terms of the CalSavers Program. If I decide to opt back in I can contact CalSavers.
— —
Signature of Employee Date (mm/dd/yyyy)
CalSavers Retirement Savings Program
