Fillable Payroll Deduction Authorization Agreement (College Foundation of North Carolina)

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Payroll Deduction Authorization Agreement (College Foundation of North Carolina)

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Employee: Complete this form to set up Contributions by payroll deduction
for up to seven Accounts in North Carolina’s National College Savings Program
(the “Program”); for more, please attach a separate page. See
Program Description for North Carolina’s National College Savings Program
(the “Program Description”) for details.
Each Account to which you contribute must be established and assigned an
Account number prior to receiving Contributions by payroll deduction. If you
are the Participant (Account owner), you must have already completed, or
return with this form, a separate Enrollment and Participation Agreement
(“Enrollment Agreement”) for each Benefi ciary.
If you are not the Participant on the Account(s), but you want to contribute by
payroll deduction for a particular Benefi ciary, you must have the Account
number to complete this request. Your Contributions become the property of
the Participant.
Employer: Upon receipt of this completed Payroll Deduction Authorization
Agreement (“Authorization Agreement”), please use the information provided
below to establish the amount of the payroll deduction for your employee and
communicate it to your payroll provider. If you send in Enrollment Agreements
for your employees, please include Authorization Agreements with those
requesting payroll deduction.
Please print clearly in capital letters and dark ink.
1
Employee Information
Check one.
Participant Contributor (Account Owner) Other Contributor (Not Account Owner)
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Employer Name
☐ ☐ ☐ ☐ ☐
Company Code
Check type and enter the number. SSN ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
TIN Social Security or Taxpayer Identifi cation Number
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
Employee Name (First, Middle, Last, Suffi x)
☐ ☐ ☐ – ☐ ☐ ☐ – ☐ ☐ ☐ ☐
Primary Telephone Number (8:00 a.m. to 5:00 p.m.)
Employee Payroll Schedule
Check one.
Once a week Every two weeks
Twice a month Once a month
Type of Transaction
Check one.
New Deduction Change Existing Deduction Stop Deduction
2
NC 529 Plan
North Carolina’s National College Savings Program
Payroll Deduction Authorization Agreement
NC 529 Plan
P.O. Box 40877
Raleigh, NC 27629-0877
NC 529 Plan
2917 Highwoods Blvd.
Raleigh, NC 27604
919-835-2304
For questions or forms, contact the Program
Administrator College Foundation, Inc.
CFNC.org/NC529 800-600-3453
919-828-4904 (Raleigh)
Mail to:
Overnight or
registered mail:
Fax to:
Make checks payable to: “NC 529 Plan”
4
Authorization — You Must Sign Below
1. I understand my Contributions per Benefi ciary in a calendar year generally may not exceed the applicable annual federal
exclusion for a Participant or other contributors without incurring federal and North Carolina gift taxes. Please refer to the
Program Description for details on any tax consequences for Contributions made to Account(s) in the Program. I also
understand that all Contributions are made post-tax and that I must consult my tax advisor for further information if needed.
I further understand that if I am not the Participant on the Account(s), my Contributions become the property of the Participant.
2. I agree that my pay will be reduced in the manner I have specifi ed above, and I affi rmatively elect to have this amount
contributed for the Benefi ciary(ies) named above in accordance with the designation of Contributions on record for the
Account(s) (one per Benefi ciary). I understand that if I wish to change the amount I am contributing each pay period, I must
complete a new Payroll Deduction Authorization Agreement.
3. I understand that my employer will transmit the amount specifi ed in this Authorization Agreement to the Program
Administrator for processing in a timely manner after deduction is made.
4. I reserve the right to revoke this authorization by completing a new Payroll Deduction Authorization Agreement and
selecting “stop deduction” or by written notice to my payroll department; however, I understand that such revocation shall
not be effective until received and duly implemented by both my payroll department (or payroll provider, as applicable)
and the Program Administrator. I agree that my employer (or payroll provider, as applicable) is not responsible for the
performance of the Investment Options offered through the Program. I also agree that my employer will incur no liability
for any losses that I may suffer as a result of my participation in the Program, and will not be responsible for any income or
other taxes that I may incur as a result of my participation in the Program. I further understand that my employer may use
the services of a fi nancial advisor to offer the payroll deduction plan, but this fi nancial advisor will not have the authority to
make any Account changes.
5. In requesting payroll deduction for this Program, I confi rm that I have read and understand the Program Description.
6. This Authorization Agreement replaces any earlier agreement with my employer concerning participation in the Program
and will continue to be effective while I am employed and my employer makes the Program available through a payroll
deduction plan, or until I revoke this authorization.
_________________________________________________________________________
☐ ☐ – ☐ ☐ – ☐ ☐ ☐ ☐
Signature of Employee Date (month, day, year)
CFI Form C426 (07/13)
CFNC.org/NC529 800-600-3453
3
Payroll Deduction Allocation
I, the undersigned employee, authorize my employer to deduct from my pay a total amount of $________________ per pay
period (minimum of $25 per Account) designated in the percentages specifi ed for each Benefi ciary listed below and to transmit
the amount deducted to the Program. Percentages must be in whole numbers, not fractions, and total 100%.
Benefi ciary’s Full Name Account Number
(if established) Percentage of
(First, Middle, Last, Suffi x) (If not yet established, an Enrollment Agreement Total Deduction Amount
must accompany this form.) Per Account
____________________________________________
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐– ☐ ☐ ☐ ☐ ☐ ☐ %
____________________________________________
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐– ☐ ☐ ☐ ☐ ☐ ☐ %
____________________________________________
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐– ☐ ☐ ☐ ☐ ☐ ☐ %
____________________________________________
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐– ☐ ☐ ☐ ☐ ☐ ☐ %
____________________________________________
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐– ☐ ☐ ☐ ☐ ☐ ☐ %
____________________________________________
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐– ☐ ☐ ☐ ☐ ☐ ☐ %
____________________________________________
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐– ☐ ☐ ☐ ☐ ☐ ☐ %
TOTAL
☐ ☐ ☐ %
100
0
Please print, sign, and mail to the NC 529 Plan to complete your
Payroll Deduction request.
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Payroll Deduction Authorization Agreement (College Foundation of North Carolina)

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Completed 9 February 2021

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