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: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439
FRM570-201311-360
REV 11/2016
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.)
p Pre-Tax Contributions: p Percentage: __ __ __ % or p Dollar Amount: $__ __ __ __ __ (per pay period)
p Roth Contributions: p Percentage: __ __ __ % or p Dollar Amount: $__ __ __ __ __ (per pay period)
Roth contributions are not available in all plans. Please check with your employer or ICMA-RC to conrm that Roth contributions are offered in your plan
before selecting this option.
Normal Contribution Limit (2017): 100% of compensation or $18,000, 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.
p Age 50 catch-up contributions (up to $6,000 more than the normal limit. $24,000 maximum.)
p Special pre-retirement catch-up (up to $18,000 more than the normal limit. $36,000 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
2017
18,000
(Approximately $692 every two weeks)
* If you are paid semi-monthly (24 pay periods per
year), contribute $750 per pay period.
$6,000
($24,000 total)
$18,000
($36,000 total)
Identication (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: _____________________________________________________________________________________________
