Fillable EMPLOYEE OPT OUT FORM

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EMPLOYEE OPT OUT FORM

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32717 Illinois Secure Choice (Rev. 8/2018) ©2018 Ascensus, LLC
1. EMPLOYEE INFORMATION (All fields required)
To verify your information, please provide either the last four digits of your Social Security Number/Taxpayer Identification Number, or your
access code and date of birth. The access code can be found in the email or letter you received from Illinois Secure Choice.
Legal Name (First) (M.I.)
Legal Name (Last)
Address
—
City State Zip Code
—
—
Telephone Number (In case we have a question) Last Four Digits of Social Security Number or Taxpayer Identification
Number
—
—
Access Code Birth Date (mm/dd/yyyy)
4. SIGNATURE
I do not wish to participate in the Illinois Secure Choice Program at this time. I understand that I can change my mind at any time and begin
participating in Illinois Secure Choice at a later date, subject to and in accordance with the terms of the Illinois Secure Choice Program. If I
decide to opt back in, I can contact Illinois Secure Choice.
—
—
Signature of Employee Date (mm/dd/yyyy)
EMPLOYEE OPT OUT FORM
Illinois Secure Choice is a completely voluntary program. You can opt out at any time online, by phone, or by completing this form. If you do
not opt out your employer will send payroll contributions to your Illinois Secure Choice 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 Illinois Secure Choice Program terms.
Every little bit you save now can potentially make a difference in retirement. To opt out of payroll contributions to Illinois Secure Choice for
more than one employer you must submit a separate form for each employer.
Completed forms should be mailed Illinois Secure Choice Overnight Address: Illinois Secure Choice
back to Illinois Secure Choice. PO Box 56000 95 Wells Avenue, Suite 155
Boston, MA 02205-6000 Newton, MA 02459
You may also opt out online or by phone.
855-650-6914
saver.ilsecurechoice.com
8 a.m. to 8 p.m. CT, Monday through Friday
3. EMPLOYER INFORMATION
Employer Name
2. 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
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EMPLOYEE OPT OUT FORM

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Completed 2 December 2021

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