Fillable MD Combined Enrollment

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MD Combined Enrollment

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DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com 1
State of Maryland
Participation
Agreement
for Pre-Tax and Roth
Retirement Savings Accounts
DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com2
Things to Remember
c Complete all of the sections on the Participation Agreement that apply to your
request.
c Complete the Authorization section, and remember to sign and date this
Participation Agreement.
c Enclose the completed Participation Agreement, and any other documentation in
the business reply envelope included with this booklet.
c All contributions will use the same investment election and allocation. If you wish to
have dierent selections, call us at 443-886-9402 or toll-free at 800-966-6355.
c Earnings from Designated Roth contributions may be subject to income taxes and
penalties upon distribution if the distribution is deemed to be Non-Qualified. A
Qualified distribution is one that the contributions are held in the Designated Roth
Account for 5 consecutive tax years and the participant is at least age 59 ½, has
become disabled or has died. In addition, Designated Roth Accounts which are
rolled over into this account may be subject to income taxes and penalties if they
are deemed Non-Qualified. Designated Roth Contributions are generally not subject
to income taxes or penalties.
c Please note that, once made, contributions and/or rollovers to a Roth account may
not be reversed. In the event you wish to make changes, only future contributions
and/or rollovers can be redirected.
DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com 3
Select Plan Type: c 457(b) Pre-Tax c 401(k) Pre-Tax c 403(b) Pre-Tax
c 457(b) Roth* c 401(k) Roth*
*Contributions to Roth are made on a post-tax basis.
Name: Social Security Number or Account Number:
Address: City, State, & Zip Code:
Date of Birth: Work Phone Number:
Email Address: Home Phone Number:
Date of Hire: Agency Code: Gender: c Male c Female
c New c Change Amount c Reinstate c Change Direction of Future Contributions
NOTE: All increases, decreases and suspensions will be implemented no sooner than the first payroll of the month following the
change. Please remember to check your pay stub to confirm your selected contributions are accurately reflected and being processed.
Dollar Amount*
Contribution Amount - Pre-Tax
Contribution Amount - Roth*
Special Amount Per Pay
Total
*Contributions to Roth are made on a post-tax basis.
Payroll Frequency:
Please select your payroll
frequency to insure timely
processing.
c Weekly
c Monthly
c Semi-Monthly
c Bi-Weekly
c Other______________
c Check here if this is a change of beneficiary. (Beneficiaries listed below replace any prior designation)
PLEASE NOTE: Percentage split must total 100% for each category of beneficiary.
If additional space for beneficiaries is required, attach additional sheets and mark this box: c
Primary Beneficiary(ies) (must total 100%):
Name Relationship Social Security # Phone #
Address Date of Birth % Split
Name Relationship Social Security # Phone #
Address Date of Birth % Split
Contingent Beneficiary(ies) (must total 100%):
Name Relationship Social Security # Phone #
Address Date of Birth % Split
Name Relationship Social Security # Phone #
Address Date of Birth % Split
Paperless Delivery: By providing your email address you are consenting to receive statements, confirmations, terms,
agreements and other information provided in connection with your retirement plan electronically. Unless you choose
to have statements, account documents and other documents sent in connection with your retirement plan delivered via
U.S. Mail to the mailing address of record by checking the box below, these documents will be made available to you
electronically. c I wish to receive my statements and account documents via U.S. Mail.
Contribution to begin on pay-period ending date:___________
Special Pay-Period Date Range: Start Date/End Date:________
(Special Amount Only) # of Pay-Periods: __________________
Payroll Type: c Regular c University
c Contractual c Other
Payroll Center Name: c Central c University c Other
Personal Information
Type of Request & Paperless Delivery Consent
Contribution Summary & Payroll Frequency
Beneficiary Designation
State of Maryland Participation Agreement
for Pre-Tax and Roth Retirement Savings Accounts
0
DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com4
PLEASE NOTE: TOTAL OF ALL FUNDING OPTIONS MUST EQUAL 100% (WHOLE % ONLY)
Fixed Income Option
_________% Investment Contract Pool
(457(b), 401(k) & 401(a) only)
_________% Vanguard Federal Money Market Fund
(403(b) only)
Bonds
_________% PIMCO Total Return Fund (Institutional Shares)
_________% Vanguard Total Bond Market Index Fund
(Institutional Shares)
Balanced
_________% Fidelity Puritan Fund
_________% T.Rowe Price Retirement Balanced Fund
Large Cap
_________% American Century Equity Growth Fund
(Institutional Shares)
_________% American Funds - The Growth Fund of America
(R6 Shares)
_________% Goldman Sachs Large Cap Value Fund
(Institutional Class)
_________% Parnassus Equity Income Fund
(Institutional Shares)
_________% Vanguard Institutional Index Fund
Mid Cap
_________% Janus Enterprise Fund (N Shares)
_________% T. Rowe Price Mid Cap Value Fund
_________% Vanguard Mid Cap Index Fund
(Institutional Plus Shares)
Small Cap
_________% T. Rowe Price Institutional Small Cap. Stock Fund
_________% Vanguard Small-Cap Index Fund
International
_________% American Funds - EuroPacific Growth Fund
(R6 Shares)
_________% Vanguard Total International Stock Index Fund
(Institutional Shares)
T.Rowe Price Target Date Retirement Funds
_________% T.Rowe Price Retirement 2005 Fund
(designed for those born in 1942 or before)
_________% T.Rowe Price Retirement 2010 Fund
(designed for those born between 1943-1947)
_________% T.Rowe Price Retirement 2015 Fund
(designed for those born between 1948-1952)
_________% T.Rowe Price Retirement 2020 Fund
(designed for those born between 1953-1957)
_________% T.Rowe Price Retirement 2025 Fund
(designed for those born between 1958-1962)
_________% T.Rowe Price Retirement 2030 Fund
(designed for those born between 1963-1967)
_________% T.Rowe Price Retirement 2035 Fund
(designed for those born between 1968-1972)
_________% T.Rowe Price Retirement 2040 Fund
(designed for those born between 1973-1977)
_________% T.Rowe Price Retirement 2045 Fund
(designed for those born between 1978-1982)
_________% T.Rowe Price Retirement 2050 Fund
(designed for those born between 1983-1987)
_________% T.Rowe Price Retirement 2055 Fund
(designed for those born between 1988-1992)
_________% T.Rowe Price Retirement 2060 Fund
(designed for those born in 1993 or after)
I authorize my employer to reduce my salary by the above amount which will be credited to the State of Maryland 457(b) Plan, 401(k),
and/or 403(b)Plan as applicable. The reduction will continue until otherwise authorized in accordance with the plan. The withholding
of my contributed amount by my employer and its payment to the designated investment option(s) will be reflected in the first pay
period after the processing of this application by the Plan Administrator in conjunction with the set-up time required by my payroll
center, however, in no case prior to the beginning of the month following the month this form is signed. The reduction is to be allocated
to the investment options in the percentages indicated above. Current pre-tax investment election and allocation will be used for Roth
contributions.
All changes will be processed when received by the Product Provider.
By signing below, you acknowledge receipt of a copy of the applicable prospectus covering the options to which your funds will be
allocated.
By signing below, you authorize Nationwide Retirement Solutions, as the Administrative Services Provider, to make the changes
indicated above.
c Please send me a copy of the Informational Brochure/Prospectus(es).
c
Please contact me about my other pre-tax investments and/or Roth investments that I would like to roll into this plan.
I HAVE READ AND UNDERSTAND EACH OF THE STATEMENTS ON THE FRONT AND BACK OF THIS FORM,
INCLUDING THE MEMORANDUM OF UNDERSTANDING WHICH HAVE BEEN DRAFTED PURSUANT TO THE
APPLICABLE PROVISIONS IN THE INTERNAL REVENUE CODE OF 1986, AS AMENDED. I ACCEPT THESE TERMS AND
UNDERSTAND THAT THESE STATEMENTS DO NOT COVER ALL THE DETAILS OF THE PLAN OR PRODUCTS.
Participant Signature: Date:
Retirement Specialist Name: Agent Number:
MAIL TO: Nationwide Retirement Solutions
11350 McCormick Road
Executive Plaza 1 - Suite 400
Hunt Valley, MD 21031
For assistance with completing this form, please call 443-886-9402 or toll-free at 800-966-6355.
Fax number: 443-886-9403
cEnroll me in asset rebalancing. I agree to comply with and be bound by the terms and conditions of the service
including any restrictions imposed by the investment options. I understand I can obtain more information about the
service, its terms and conditions by contacting the NRS Service Center.
Funding Options
Authorization
DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com 5
The purpose of the Memorandum of Understanding is to make you aware of the highlights, restrictions and cost of your
plan. It is not intended to cover all specific details of the plan.
I understand that my participation in the Plan is governed by the terms and conditions of the Plan Document.
I understand and acknowledge the following:
1. REGARDING 457(b) PLANS:
The combined total annual pre-tax or Roth contribution amount to all 457(b) plans is the lesser of $18,000 or
100% of includible compensation. Under certain circumstances, additional amounts above the limit may be
deferred into the Plan if (1) I will attain age 50 or older during the current calendar year, or (2) I am within three
years of Normal Retirement Age and did not defer the maximum amount in prior years. The Plan Document
provides additional details about contribution limits. Contributions in excess of maximum amounts are not
permitted and will be considered taxable income when refunded. It is my responsibility to ensure my
contributions do not exceed the annual limit.
It is my responsibility to adjust my contribution amount to comply with the law. Excess contributions will be
returned to me and reported on a 1099R tax form. I acknowledge that it is my responsibility to make sure my
total contributions, including any 457(b), 403(b) and/or 401(k) Plan Contributions, fall within the specified limits.
A Nationwide Retirement Solutions Representative can provide assistance in determining my contribution limits.
All withdrawals of funds must be in compliance with the Internal Revenue Code and applicable regulations, some
of which are expressed in the Plan Document.
Funds may be withdrawn from the plan ONLY when one of the following events occurs:
•Termination of State Employment
•Attaining age 70 ½ even if still employed.
•Unforeseeable Emergency approved by the plan
•Total Disability
•Death
•When taking a loan
•In some cases a transfer for purchase or repayment of service credits in a Governmental Defined
Benefit Plan may be permitted.
Roth distributions not meeting the criteria for a qualified distribution may be subject to income tax and a 10%
penalty.
2. REGARDING 401(k) PLANS:
My combined total annual pre-tax or Roth contribution is subject to contribution limitations described in
Sections 415(c) and 402(g) of the Internal Revenue Code. My maximum contribution will be the lesser of
$18,000 or 100% of my compensation under section 415 of the Code. Additional amounts above the limit may
be deferred into the Plan if I will attain age 50 or older during the current calendar year. I understand that
current or future participation in additional benefit plans, such as 403(b) and/or 401(a) plans, may aect my
maximum annual contribution limit under the Maryland 401(k) Plan, in accordance with the U.S. Internal Revenue
Code.
It is my responsibility to adjust my contribution amount to comply with the law. Excess contributions will be
returned to me and reported on a 1099R tax form. I acknowledge that it is my responsibility to make sure my
total contributions, and other 403(b) Plan and/or 401(k) Plan, including Roth, contributions, fall within the
specified limits. A Nationwide Retirement Solutions Representative can provide assistance in determining my
contribution limits.
Funds may be withdrawn from the plan ONLY when one of the following events occurs:
•Termination of State Employment (an early withdrawal penalty may apply if your separation from state
service is prior to the age of 55.)
•Attaining age 59 ½ even if still employed.
•Financial Hardship (a 10% early withdrawal penalty tax may apply prior to age 59 ½)
•Total Disability
•Death
•When taking a loan
•In some cases a transfer for purchase or repayment of service credits in a Governmental Defined
Benefit Plan may be permitted.
Roth distributions not meeting the criteria for a qualified distribution may be subject to income tax and a 10%
penalty.
State of Maryland Retirement Plan
Memorandum of Understanding
DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com6
If applicable, amounts contributed to the 401(a) match account, when the Match Program is in eect, do not aect
employee 401(k) limits but may impact elective contributions or employer contributions made on my behalf into other
retirement plans. I acknowledge that I am responsible for monitoring these limits and notifying the Plan Administrator if
necessary.
3. REGARDING 403(b) PLANS (available for education employees only):
My total annual contribution is subject to contribution limitations described in Subsection 403(b) of the Internal
Revenue Code. My maximum contribution will be the lesser of $18,000 or includible compensation as defined
under Section 415 of the Code, or my basic exclusion allowance. I understand that current or future
participation in additional benefit plans, such as 401(k) plans, may aect my maximum annual contribution limit
under the Maryland 403(b) Plan, in accordance with the U.S. Internal Revenue Code.
It is my responsibility to adjust my contribution amount to comply with the law. Excess contributions will be
returned to me and reported on a 1099R tax form. I acknowledge that it is my responsibility to make sure my
total contributions and other 403(b) Plan and/or 401(k) Plan Contributions, fall within the specified limits. A
Nationwide Retirement Solutions representative can provide assistance in determining my contribution limits.
Funds may be withdrawn from the plan ONLY when one of the following events occurs:
• Termination of State Employment (an early withdrawal penalty may apply if your separation from state
service is prior to the age of 55.)
• Attaining age 59 ½ even if still employed.
• Financial Hardship (a 10% early withdrawal penalty tax may apply prior to age 59 ½)
• Total Disability
• Death
• When taking a loan
• In some cases withdrawal for purchase or repayment of service credits in a Governmental Defined
Benefit Plan may be permitted.
If applicable, amounts contributed to the 401(a) match account, when the Match Program is in eect, do not
aect employee 403(b) limits but may impact elective contributions or employer contributions made on my
behalf into other retirement plans. I acknowledge that I am responsible for monitoring these limits and notifying
the Plan Administrator if necessary.
REGARDING ALL PLANS
4. The fund prospectuses are available upon request at marylanddc.com or by calling 800-545-4730.
5. I must notify Nationwide Retirement Solutions of any address changes, beneficiary changes, contribution
amount changes, allocation changes or errors on my account statement.
6. I may reallocate my contribution amount any time without limitation.
7. Contributions, in the form of salary reductions, will be made each pay period until I notify Nationwide
Retirement Solutions otherwise. A short delay may exist before my contributions are invested due to the time
required to place the money into the investment options.
8. I will receive a statement of my account quarterly.
9. My distributions must begin no later than April 1st following the year I reach age 70½. If I work beyond age 70
1/2, my distributions must begin no later than April 1st following the year I separate from service or retire. All
distributions are taxable as ordinary income and subject to income tax in the year received. My distributions
must be made in a manner that satisfies the minimum distribution requirements of IRC Sec. 401(a)(9), which
currently requires benefits to be paid at least annually over a period not to extend beyond my life expectancy
Failure to meet minimum distribution requirements may result in the payment of a 50% federal excise tax.
10. The funds in my account may be eligible for rollover to a traditional IRA or to an eligible retirement plan. The
“Special Tax Notice Regarding Plan Payments” provides detailed information about my options. Due to
important tax consequences related to distributions, I have been advised to consult a tax advisor. I expressly
assume the responsibility for tax consequences relating to any distribution, and I agree that neither the Plan nor
the Plan Administrator shall be responsible for those tax consequences.
11. Eligible Rollover Distributions are subject to 20% Federal Income Tax withholding.
12. The share value calculated at the time of exchange depends on the investment option. Contact your Nationwide
Retirement Solutions representative for specific information for each investment option.
13. All telephone exchange requests will be recorded for the participant’s protection.
14. The value of my account in my chosen mutual funds can fluctuate and result in a gain or loss depending on the
market activity.
15. An annual asset fee up to 0.14% will be assessed on my account balance. Part of this fee, 0.05%, supports the
Maryland Teachers and State Employees Supplemental Retirement Plans’ Board of Trustees’ budget. The
remaining 0.09% goes toward services provided by Nationwide Retirement Solutions. No account will be
charged a combined board fee and Nationwide Retirement Solutions fee of more than $2,000 annually. A
Nationwide Retirement Solutions representative can provide further details.
State of Maryland Retirement Plan
Memorandum of Understanding
DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com 7
16. The investment options available under the plan are selected by the Maryland Teachers and State Employees
Supplemental Retirement Plans’ Board of Trustees and are subject to a periodic review by the Board, its sta and
its Investment Advisor to assure that the options continue to meet established criteria. The Board reserves the
right to add additional funds to the plan and replace or remove existing funds. If existing funds are replaced, the
Board reserves the right to require or direct the transfer of existing balances and ongoing contributions from any
fund which has been eliminated as an option within the same risk category that I had previously selected.
17. I have received an explanation of the fixed option and understand that the rate of return produced by that
option will vary over time, depending on the rates paid by the contracts that make up the fixed option
(457(b), 401(k) & 401(a) only).
18. Money allocated to each Investment Contract Pool, as selected by the Board, will earn a fixed rate of interest for
the contract term as selected by the Board. Participation in the fixed option will result in a blended interest rate
based upon the Investment Contract Pools used to determine my account value. I understand that an Investment
Contract Pool is not a mutual fund (457(b), 401(k), & 401(a) only)
19. Transfers between investment options are provided for under the Plan subject to limitations or restrictions
(including redemption fees), if any, as imposed by the investment providers. I understand that any information
regarding limitations or restrictions as they apply to the Plan may be obtained from the Plan Administrator.
20. If applicable, I understand that no changes will be eective until they are processed by Nationwide Retirement
Solutions.
21. Distribution from the 401(a) account may occur at the time of the participant’s death, disability, or separation of
service. Withdrawals from the 401(a) account prior to age 59 ½ may be subject to a 10% federal tax penalty for
early withdrawal.
22. Targeted Retirement Funds are managed by T. Rowe Price and are composed of other T. Rowe Price mutual
funds. There is no guarantee that the investment objective of any fund will be achieved. Investment return and
principal value will fluctuate, so that an investor’s shares, when they are redeemed, may be worth more or less
than their original cost. The Targeted Retirement Funds are designed to provide diversification and asset
allocation across several types of investments and asset classes, primarily by investing in underlying funds.
Therefore, you are indirectly paying a proportionate share of the applicable fees and expenses of the underlying
funds.
23. Nationwide Retirement Solutions, Inc. and Nationwide Life Insurance Company have endorsement relationships
with the National Association of Counties and the International Association of Firefighters-Financial Corporation.
More information about the endorsement relationships may be found online at nrsforu.com.
24. Financial & Realty Services, LLC may provide education and marketing support services on behalf of NRS. Its
Retirement Consultants are registered representatives of FSC Securities Corporation (FSC), member FINRA,
SIPC. FSC and Financial & Realty Services, LLC are not aliated with MSRP, NRS or NISC.
CONSENT TO PAPERLESS DELIVERY AND ACCESS
By providing your email address here, you are agreeing and consenting to receive and view plan benefit
statements, correspondence and confirmations, and other communications electronically. These materials will be
provided through an email message notifying you that electronic documents are available online for you to view
and print. This replaces all written communication associated with your Retirement Plan(s) serviced by
Nationwide and you will no longer receive these documents via U.S. Mail. By providing your consent to
paperless delivery, you are acknowledging and confirming that you are consenting to receive Plan
Communications electronically, as they are now available or as they may be required or become available in the
future and that you have access to view and print your documents electronically from the website and to save
them from your computer or other electronic device. If you would like to receive the above referenced
documents in paper form via U.S. Mail you can do so by contacting Customer Service at (1-800-966-6355) and
requesting paper. You may opt out of paperless delivery of your plan related documents at any time. There is no
additional cost to receive documents in paper format via U.S. Mail.
CHANGING YOUR EMAIL ADDRESS AND YOUR PAPERLESS DELIVERY PREFERENCES
You are able to update your email address or change your Paperless Delivery Preferences anytime either on the
website or via Customer Service.
YOUR RIGHT TO REVOKE CONSENT
You have the right to revoke your consent to receive documents electronically. Your consent shall be eective
until you revoke it by changing your delivery preferences via Customer service or on the website by selecting
U.S. Mail delivery.
State of Maryland Retirement Plan
Memorandum of Understanding
DC-4531 (08/2016) For help, please call 800-966-6355 marylanddc.com8
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MD Combined Enrollment

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Completed 21 July 2020

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