HELPLINE: 1-800-422-8463
WWW.NYSDCP.COM
ENROLLMENT APPLICATION
q Male
__________________________________________________________________
q Female ________________________________
Name (Please Print)
Social Security Number
____________________________________________________________________________ ________________________________
Home Address
Date of Birth
____________________________________________________________________________ ________________________________
City State Zip Home Telephone Number
____________________________________________________________________________ ________________________________
Employer Work Telephone Number
______________________________________________________________________________________ ________________________________
Email Address (Required Please see eDelivery section for additional detail) Local Plan ID Number or
State Department ID Code*
________________________________
New York State Employee ID Number*
*If you are unaware of this number, please contact your Payroll Center or the
HELPLINE as your enrollment cannot be completed without it. Department ID can also
be found on your State Paystub.
If your employer is a local town, village, or school, please check with your payroll department or the HELPLINE to determine whether to
request a deferral dollar amount or percentage. Also, if your employer is a school and utilizes OMNI as a third-party payroll administrator please
contact OMNI to complete the enrollment of your deferral request
You may select both Pre-tax and Roth. Maximum combined deferral percentage is 100%. If you are paid through the State Comptroller,
please enter a deferral PERCENTAGE.
Pre-Tax Deferral: _______% or $: _________ Roth Contributions: ______% or $: _________
Your deferral cannot be less than 1% of your gross salary or less than $10 per pay period.
Please complete all requested information for each of your primary and contingent beneficiaries. A person may not be listed as both a primary and
contingent beneficiary. If you select “Equal Percentage” for your beneficiaries, there may be some minor variance based upon the number of
beneficiaries you have listed. For example, if you list three beneficiaries, the oldest beneficiary will be designated 33.34% and the other two will be
33.33%.
Primary Beneficiary(ies): A primary beneficiary is the person or persons who receive your Plan benefits in the event of your death.
Contingent Beneficiary(ies): A contingent beneficiary is the person or persons who would receive your Plan benefits if all of your
primary beneficiaries predecease you.
Primary Beneficiary (ies) (must be in whole percentages and total 100%)
q
Equal percentages for each primary beneficiary
____________________________ _____________________________ ______________ ___________________ _____%
Beneficiary Name Relationship Date of Birth Social Security Number Percent
____________________________ _____________________________ ______________ ___________________ _____%
Beneficiary Name Relationship Date of Birth Social Security Number Percent
____________________________ _____________________________ ______________ ___________________ _____%
Beneficiary Name Relationship Date of Birth Social Security Number Percent
Total = 100%
Contingent Beneficiary(ies) (must be in whole percentages and total 100%)
q
Equal percentages for each contingent beneficiary
____________________________ _____________________________ ______________ ___________________ _____%
Beneficiary Name Relationship Date of Birth Social Security Number Percent
____________________________ _____________________________ ______________ ___________________ _____%
Beneficiary Name Relationship Date of Birth Social Security Number Percent
Total = 100%
BENEFICIARY DESIGNATION
DEFERRAL INFORMATION
PERSONAL DATA
Account Executive #
Internal Use Only
Write the percentage you wish to allocate to each investment option. You may allocate your salary deferrals among any of the investment
options listed below. The allocation of your contributions may be in any whole percentage and must total 100%.
DO IT FOR ME
The following investment options are professionally managed asset allocation funds based on your expected
retirement date:
VRU#
______% (1776) TRP Retirement Date 2010 Trust (CIT)
______% (1777) TRP Retirement Date 2015 Trust (CIT)
______% (1778) TRP Retirement Date 2020 Trust (CIT)
______% (1779) TRP Retirement Date 2025 Trust (CIT)
______% (1780) TRP Retirement Date 2030 Trust (CIT)
VRU#
______% (1781) TRP Retirement Date 2035 Trust (CIT)
______% (1782) TRP Retirement Date 2040 Trust (CIT)
______% (1783) TRP Retirement Date 2045 Trust (CIT)
______% (1784) TRP Retirement Date 2050 Trust (CIT)
______% (1785) TRP Retirement Date 2055 Trust (CIT)
______% (1786) TRP Retirement Date 2060 Trust (CIT)
The following core investment options permit participants to create their own asset allocation:
DO IT YOURSELF
Stable Income Fund
______% (2756) NYSDCP Stable Income Fund
Bond Funds
______% (1788) NYSDCB US Debt Index U/A (CIT)
______% (1794) Voya Core Plus Trust Fund (CIT)
Balanced Funds
______% (8957) Vanguard Wellington FundAdmiral
(MF)
Large Cap Funds
______% (1789) NYSDCB Equity Index U/A (CIT)
______% (1787) Boston Partners Large-Cap Value Equity
Fund (CIT)
______% (1791) T. Rowe Price Equity Income Trust (CIT)
______% (1792) T. Rowe Price Blue Chip Growth Trust
(CIT)
______% (2765) Vanguard PRIMECAP FundAdmiral
(MF)
SMID Cap Funds
______% (1790) NYSDCB Russell 2500 Index U/A (CIT)
______% (653) Vanguard Strategic Equity Fund (MF)
Small Cap Funds
______% (1692) Delaware Small-Cap Value Fund CL I (MF)
______% (1793) T. Rowe Price QM US Small-Cap Growth Equity
Fund CL I (MF)
International Funds
______% (5025) NYSDCP International Equity Fund - Active
______% (5030) NYSDCP International Equity Fund - Passive
Emerging Markets
______% (1458) MSIF Emerging Markets PortfolioInstitutional
(MF)
Specialty Options
______% (7298) Pax World Balanced FundInstitutional (MF)
______% (195) Fidelity OTC Fund (MF)
100 % (MUST TOTAL 100%)
Some mutual funds may impose a short-term trade fee. Please read the
underlying prospectuses or factsheets carefully
I agree to the terms of the New York State Deferred Compensation Plan. I authorize my employer to deduct the amount or percentage set
forth herein until I provide further notice for the purposes of contributing it to my Plan account. I further authorize my employer to process
any deferral changes I request through the Plan in the future. Deferrals made by participants who are not New York State residents may be
subject to the state income tax in the year deferred in their state of residence. Please read your state income tax instructions carefully.
___________________________________________________________ ______________________
Participant Signature Date
DC-4009-0617
DEFERRAL ALLOCATION
AUTHORIZATION
EDELIVERY OPT OUT
understand that by not checking this box, I elect eDelivery for quarterly statements, newsletters, investment performance reports and
confirmations. With eDelivery, I will be emailed this information at the address provided under the Personal Data section when the
Welcome to the New York State Deferred Compensation Plan. The Plan is a voluntary, long-term retirement savings program
designed for your retirement needs. The amount you contribute to the Plan is deducted from your pay and any investment
returns grow on a tax-deferred basis.
Contributions to the Plan: The minimum contribution to the Plan is 1% of your gross pay (at least $10 per pay period). The
maximum contribution you may make in 2017 is $18,000. If you are at least age 50 prior to the end of the current calendar
year, you are eligible to contribute a maximum of $24,000. If you are within four years of the date that you are able to retire
without a reduction in pension benefits, you may be eligible to make additional contributions. Contact an Account Executive
or HELPLINE Representative at 1-800-422-8463 for more information and the forms to use the higher limits.
Pre-Tax Deferrals: The amount you contribute to the Plan will be deducted from your pay on a pre-tax basis for federal and
New York State income tax purposes, thereby reducing your taxable income for the calendar year. The investment returns
also grow on a tax-deferred basis and income taxes are paid only when money is withdrawn from the Plan.
Roth Contributions: These deductions are made from your pay on an after-tax basis. Contributions grow tax deferred, but
when money is distributed from the Plan, qualifying distributions are not subject to federal or New York State income taxes.
Processing Time Frame: Enrollments are processed upon receipt; however, federal law states that deferrals may not begin
before the start of the next calendar month, unless you make your election prior to your first day of service. You may change
or cancel your deferral amount at any time, but these changes may also be subject to these timing limits.
Next Steps: Please read the bullets below to understand the basics of the Plan and then complete your application.
I understand that:
Withdrawals from the Plan may be taken only upon separation from employment, absence due to qualified military
service, death, an unforeseeable financial emergency, attainment of age 70½ , from an account that has been in
inactive status for two years and has a balance of $5,000 or less (inclusive of any outstanding loan balance but
exclusive of assets in a rollover account) or as a loan.
Participation in the Plan is not intended to replace a regular savings program necessary to cover day-to-day
unanticipated financial expenses. Plan distributions for “Unforeseeable Financial Emergencies” are strictly regulated
by federal laws. Should I need an unforeseeable emergency distribution, the request must be made in writing and
detail the circumstances supporting the financial emergency. If my request is denied, I may appeal to the Review
Committee.
I may enroll in the Plan for the purpose of transferring assets from another 457(b) deferred compensation plan, a
403(b), 401(k), 401(a), Keogh plan, a traditional or rollover IRA without becoming an active participant.
Unless I have opted for a paper statement, I will receive an email notification when my quarterly statement,
Quarterly newsletter and investment performance report are available on the Web site. Please call the HELPLINE
promptly with any changes.
If my employer has opted to allow Roth contributions, contributions to the Roth account may not be reclassified
after made. The investment allocation for Roth contributions will be the same as for any pre-tax deferrals.
Distributions of Roth contributions must meet the same withdrawal requirements as pre-tax withdrawals.
There is an administrative fee deducted from my Plan account on a semi-annual basis as outlined in the Plan’s
Investment Options Guide. These fees are subject to change.
Information relating to the Plan or a copy of the Plan Document may be obtained by calling the HELPLINE at 1-800-422-
8463 or visiting the Plan’s Web site at www.nysdcp.com.
DC-4009-0617
ENROLLMENT APPLICATION
Tips for Completing the Application
State Employees
If you are employed by a State Agency, please see the screen shot below to assist you with identifying the information
necessary to complete the application.
This application will require you to include your five-digit Department ID, which is located on the upper left corner of your
pay stub, and your NYS Employee ID that is listed next to the Department ID. If you do not have this information, your
application cannot be processed.
Local Employees
If you are employed by a city, town, or library system that contains its own payroll department, the application requires your
Local Plan ID. This six-digit number can be obtained by contacting your payroll department or our HELPLINE at 1-800-422-
8463.
Deferral Information
State Employees
When entering your deferral amount, you must provide a percentage of your gross pay. This percentage must be a whole
number. If you need assistance calculating a percentage for your deferral, please contact our HELPLINE at 1-800-422-8463.
Local Employees
Before completing your application, please check with your employer or our HELPLINE to find out if your employer
requires deferrals to be entered as a dollar amount or as a percentage.
100% Deferrals
Please note that if you elect a deferral rate of 100%, you are authorizing the Plan to deduct the remaining balance of your
paycheck after all other required pre-tax deductions have been taken. If you are electing this deferral percentage for a lump
sum payment to the Plan, it is important to contact the HELPLINE with the exact date of the lump sum payment.
Return to: New York State Deferred Compensation Plan
Administrative Service Agency
P.O. Box 182797
Columbus, OH 43218-2797
Overnight Address: New York State Deferred Compensation Plan
Administrative Service Agency, DSPF-F2
3400 Southpark Place, Suite A
Grove City, OH 43123-4856
OR Fax to: 1-877-677-4329
When faxing paperwork, please allow two hours from receipt for it to be processed
If your fax is sent after 3 p.m. your paperwork will be processed on the next business day
DC-4009-0617
FORM RETURN