Fillable Form 1.: Your Beneficiary n on ti a (Motlow State Community College)

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Form 1.: Your Beneficiary n on ti a (Motlow State Community College)

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1.
P
ar
t
i
c
ipa
n
t
In
f
or
m
a
ti
on
Participant Enrollment Form
401(k) and 457(b) Plans
98986-02 98986-01
La
st
F
ir
st
Name MI
Name Address - Number & Street
City State Zip Code
Social Security
Nu
mber
E-Mail Addr
ess
Female Male
Mo
Day Year
Mo Day Year
Home Phone
Work Phone Date of Birth Date of Hire
State (Department Name)
UT TBR (Campus Name)
Local Government
Do you have a retirement savings account with a previous employer or an IRA? Yes No
2.
Choose
Your Beneficiary
List
beneficiary(ies)
below. If you are
participating
in both plans, the below beneficiary elections will apply to both plans, unless you
complete separate beneficiary change forms.
Designated percentages must be whole numbers and must add up to 100% for primary and 100% for contingent beneficiaries.
Designate
Whole
Primary Beneficiary Name(s)
Contingent Beneficiary Name(s)
Relationship
Relationship
Social Security Number
Social Security Number
Date of Birth
Date of Birth
Percentage
%
%
%
Designate Whole
Percentage
%
%
%
Plan Beneficiary Designation
Subject to and in accordance with the terms of the Plans, I am making the above beneficiary designations for my vested account(s) in the event of my
death. If I have more than one primary beneficiary, the account(s) will be divided as specified. If a primary beneficiary predeceases me, his or her benefit
will be allocated to the surviving primary
beneficiaries.
Contingent beneficiaries will receive a benefit only if there is no surviving primary beneficiary, as
specified. If a contingent beneficiary predeceases me, his or her benefit will be allocated to the surviving contingen
t
beneficiaries.
If I fail to designate
beneficiaries or if all of the above beneficiaries predecease me, amounts will be paid first to my surviving spouse, and if there is none, to my estate. This
designation is effective at the time it is recorded to my account by the State's record keeper, which is currently Empower Retirement Services. If any
information is missing, additional information may be required prior to recording my beneficiary designation. This designation supersedes all prior
designations. Beneficiaries will share equally if percentages are not provided and any amounts unpaid upon death will be
divided equally. Primary and
contingent beneficiaries must separately total 100% in whole percentages. If I designated a minor beneficiary, I also noted above the name of the
guardian or parent, if other than myself. Designated ROTH, 401(k) and 457 deferrals are subject to different distribution limits. I understand that I may
change my beneficiary designation at any time by filing a Beneficiary Change Form with the State’s record keeper.
3.
Plan and Contribution Election
I elect to enroll and participate in the following plan(s) and authorize my employer to deduct and defer the amounts shown per pay period.
Effective date must be at least 30 days after completion of this agreement.
Dollar Amount
Percentage
401(k) plan Deduct $ 401(k) pre-tax from my gross pay, per pay period. or %
401(k) plan ROTH
Deduct $
401(k) designated Roth after-tax from my gross pay, per pay period. or %
457(b) plan
Deduct $
457(b) pre-tax from my gross pay, per pay period. or %
Total: $ Total % or
%
Effective / / 20
N
ote:
Amounts must
be
between $10.00
-
$18,000.00
or 1% -
100%
per
pa
y
period
of
compensa
tion;
Month Day Year for those paid
monthly,
the
minimum contribution
per
month
is
$20.00
or 1%.
Note: Your annual deferral cannot exceed the lesser of 100% of your eligible compensation or $18,000 per plan for the 2016 calendar year. State and Higher Education employees may enroll in both plans. If you are employed with a
Political Subdivision, you may enroll in both plans if the Political Subdivision has elected to offer you both plans. 401(k) Plan deferrals of State employees may be eligible for an employer match, subject to annual appropriation.
[See Back] Page 1
0
0
Last Name First Name MI Social Security Number
4.
In
vestme nt Option
In
f
or
m
a
tion ( Choose from Sections A, B or C)
A. Enroll me in the Default Fund, which is an age, based Target Date Fund.
Investment Option: By selecting this option, my contributions will be allocated to the Plan’s default investment fund
without additional action by me. If I wish to contribute to any of the investment options of the Plan other than
the default
fund, I understand that I must complete Part B of the Participant Enrollment Form or Part C and enroll in Managed
Accounts. The Plan has selected a TARGET DATE portfolio of funds as its default investment fund.
Until such
time as
you choose investment options for your Plan account,
your contributions will be invested in the fund within the Target
Date portfolio that most closely corresponds to certain factors in your profile. For more information, please contact your
Empower Representative. I acknowledge that information about Plan investment options, including prospectuses,
disclosure documents and Fund Data sheets are available to me through the Empower website (www.gwrs.com) or Plan
Web site
(www.treasury.tn.gov/dc/).
I understand the risks of investing and that all payments and account values may not
be guaranteed and may fluctuate in value.
B. I prefer to choose my own fund line up as follows.
457(b)
Select Investment Options
Code
International
%
%
DFA International Value Fund I
DFIVX
%
%
Fidelity International Discovery Fund
FIGRX
Small Cap
%
%
Brown Capital Management Small Company Fund
BCSIX
%
%
Invesco Van Campen Small Cap Growth Fund *
INGMSC
Mid
Cap
%
%
Janus Enterprise Fund
JDMNX
%
%
Columbia Midcap Value Z *
INGCMC
Large Cap
%
%
Allianz NFJ Large Cap Institutional *
INGALG
%
%
Fidelity Contra Fund
FD-CNT
%
%
Fidelity OTC Portfolio
FD-OTC
%
%
Vanguard Institutional Index Fund
VINIX
Balance
%
%
Fidelity Puritan Fund
FD-PUR
%
%
Tennessee Treasury Managed Fund
TN-TMF
Bond
%
%
Vanguard Total Bond Market Index
VBTIX
%
%
Western Asset Core Plus Bond IS
WAPSX
Fixed
%
%
Voya Fixed Account
AEF-FX
%
%
Nationwide Bank
TN-NBA
Vanguard Target Date Funds
%
%
Vanguard Target Retirement 2010
VIRTX
%
%
Vanguard Target Retirement 2015
VITVX
%
%
Vanguard Target Retirement 2020
VITWX
%
%
Vanguard Target Retirement 2025
VRIVX
%
%
Vanguard Target Retirement 2030
VTTWX
%
%
Vanguard Target Retirement 2035
VITFX
%
%
Vanguard Target Retirement 2040
VIRSX
%
%
Vanguard Target Retirement 2045
VITLX
%
%
Vanguard Target Retirement 2050
VTRLX
%
%
Vanguard Target Retirement 2055
VIVLX
%
%
Vanguard Target Retirement 2060
VILVX
%
%
Vanguard Retirement Income
VBTIX
Total
Percentages must be whole numbers and columns must add up to 100% * Indicates separate account funds offered through Voya.
C. Enroll me in Managed Accounts.
0
0
5. P
ar
t
i
c
ipa
nt
A
greement
I understand that funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund’s
prospectus or other disclosure documents. I understand that I have the right to direct the investment of my account and that I can change my investment allocation
from the Plan’s default fund at any time by logging on to my account at www.treasury.tn.gov/dc or by calling KeyTalk at 1-800-922-7772. A personal identification
number (PIN) that will give me access to my account via the Web or phone will be mailed to me soon after my application is processed. I acknowledge that I am
responsible for keeping the assigned PIN confidential and that I must notify Empower if I suspect unauthorized use.
I have received a copy of the Deferred Compensation Plan Document and understand the terms and provisions thereof.
The Plan Document is incorporated into this Participation Agreement and that these together constitute my entire rights and obligations under the Plan. This form
is a legally binding contract. I understand that by signing and submitting this Participant Enrollment form for processing that I am requesting to have investment
options established under the Plan(s) as specified on this form. I understand that this account is subject to the terms of the Plan Document.
Account balances shall only be distributed under the terms of the Plan Document, which prohibit any payouts as long as I continue in employment with the State or
a participating Political Subdivision except in the case of financial hardship as defined by applicable 401(k) plan regulations or at age 59 1/2. Special penalty and
limitations may apply to 401(k) distributions and designated Roth 401(k) deferrals. Limits on 457 hardships are more restrictive than 401(k). Requirements vary by
plan.
I understand that the maximum annual limit on contributions is determined under the Plan Document and/or the Internal Revenue Code. I understand that it is my
responsibility to monitor my total annual limit on contributions to ensure that I do not exceed the amount permitted. If I exceed the contribution limit, I assume
sole liability for any tax, penalty, or cost that may be incurred. I understand that Federal income tax is deferred on allowable pre-tax contributions and the earnings
thereon until such amounts are distributed. I understand that Roth 401(k) contributions, earnings, and distributions are treated differently.
I understand that in the event my Participant Enrollment form is incomplete, or it is not received by Empower in Nashville, Tennessee prior to the receipt of any
deposits, I consent to Empower retaining all monies received and allocating them to the default investment option, which is selected by my Plan. I understand that
once my account has been established, I can transfer monies from the default investment option by logging onto my account at
www.treasury.tn.gov/dc or by
calling KeyTalk at 1-800-922-7772. Also, I understand that all contributions received after my account is established will be applied to the investment options I
selected. I also understand that it is my obligation to review my confirmations and quarterly statements and inform Empower of any discrepancies or errors within
90 calendar days of the date of such confirmation or statement.
401(k) and 403(b) share a single contribution limit of $18,000 for 2016. I understand that I am responsible for any excess contributions and taxes thereon.
I understand that fees may apply under the Plan(s) I selected above. The fees vary by fund and are on the Plan's Web site (www.treasury.tn.gov/dc/).
Required Signature- I have completed, understand, and agree to all pages of this participant enrollment form.
Participant Signature: Date:
For more information regarding the 401(k) and
457 plans, visit: www.tn.gov/treasury/dc or call
Empower Retirement Services at
1-800-922-7772, Option 2
Send Completed Forms to:
Empower Retirement Services
545 Mainstream Drive
Suite #407
Nashville, TN 37228
Fax 615-256-5280
Last Name First Name MI Social Security Number
Page
3
5. Participant Agreement
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Form 1.: Your Beneficiary n on ti a (Motlow State Community College)

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Completed 27 July 2020

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