Fillable State of Connecticut - Form 457 Participation Agreement

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State of Connecticut - Form 457 Participation Agreement

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Order #155629 01/01/2012
MAIL COMPLETED FORM TO:
ING Life Insurance and Annuity Co.
PO Box 990069
Hartford, CT 06199-0069
Telephone: 800-784-6386
STATE OF CONNECTICUT
DEFERRED COMPENSATION § 457 PLAN
PARTICIPATION AGREEMENT
CO-783 REV. 01/2012
www.CTdcp.com
Read the reverse side of this form and the Plan document carefully before completing this agreement. Please type or print clearly in ink.
The Office of the State Comptroller must approve all requests. You may not alter any of the printed information on this document. If you
make a mistake, you must complete a new form.
New Participant 457 Change Request
Type of
Agreement
F I am a New
Participant
Date of Hire
F Name F Address F Deferral Amount Increase
F Deferral Amount Decrease F Suspend
Name & Address of Employing Agency
Social Security Number Department ID
Participant (last, first, middle initial) Former Name (if applicable)
Employee Number
Street Address Sex
F F F M
Date of Birth
City, State, Zip Code Office Telephone No. Home Telephone No.
Participant
Information
Please print
Personal E-mail Address
Deferral
Amount
DEFERRAL AMOUNT: Minimum $20.00 per pay period. Deferral amount must be in whole dollars. Complete Catch-up
Contribution Section below, if applicable.
F PRE-TAX DEFERRAL - I elect to defer from my total compensation, $______________ per pay period, effective
check dated _____/_____/_____
F POST-TAX (ROTH) DEFERRAL - I elect to defer from my total compensation, $______________ per pay period, effective
check dated _____/_____/_____
Catch-Up
Contribution
Election
You must elect your Normal Retirement Age before you will be permitted to make any Catch-up Contributions under the Plan.
I hereby elect age _______ as my Normal Retirement Age, which I will attain in 20_____. I understand that this election is
irrevocable and cannot be changed (See reverse side for definition of Normal Retirement Age).
F AGE 50+ CATCH-UP OPTION – Available to employees who will be at least age 50 by December 31
st
of the
calendar year.
F SPECIAL SECTION 457(b) CATCH-UP OPTION – Only available during the three consecutive years before but not
including the year you attain Normal Retirement Age. You must complete the Special § 457(b) Catch-up Underutilization
Worksheet to demonstrate eligibility for this option.
457(b) Catch-up Start Date ___________ 457(b) Catch-up End Date ___________
I understand my deferral election will remain in effect until I separate from State service, change my deferral amount, reach the maximum annual limit,
or have my deferral suspended. I understand that Deferred Compensation § 457 Plan (Plan) benefits are only payable (1) upon retirement or separation
from State service; (2) due to death; (3) for an unforeseeable emergency as defined in the Plan document or (4) for a one-time in-service distribution
where the total value of my account under the Plan is less than $5,000 and I have not deferred any compensation into the Plan for at least a two-year
period ending on the date of the withdrawal request. THIS IS NOT A SAVINGS ACCOUNT. I acknowledge receipt of the Plan document and confirm I
understand the terms, provisions and conditions thereof; which terms, provisions and conditions are hereby incorporated into this Participation
Agreement and constitute my entire rights and obligations under the Plan. I understand the Plan is administered in accordance with Section 457 of the
Internal Revenue Code and any applicable regulations. I acknowledge that as a Participant, I am solely responsible for any investment gain or loss,
charge or expense of any kind under this Plan, by virtue of my account upon which benefits under the Plan are based. I agree that neither the State, my
Employing Agency, nor ING represents or guarantees any tax consequence will occur because of my participation in this Plan and I shall be
responsible to consult with and rely upon my own legal, accounting or other representative concerning all questions about tax and investment
consequences arising from my participation in this Plan. I understand participation in this Plan is voluntary. In return, I, my heirs and successors hold
harmless the State, my Employing Agency, its employees, officials, assignees, and successors from any and all liability for all acts in good faith. I
understand my deferral election can be suspended at any time by completing a new Participation Agreement; however, compensation already
deferred into the Plan cannot be withdrawn except for the benefit payment reasons noted above.
Participant’s Signature
Date
Representative’s Signature
Rep Code Date
Official Use Only
F LPC
MAIL THE ORIGINAL SIGNED
FORM
TO
THE
ADDRESS INDICATED
AT THE
TOP OF THIS FORM
MAKE
A COPY FOR
YOUR
RECORDS
RESET FORM
Order #155629 01/01/2012
CO-783 Rev. 12/2011
Type of
Agreement
This agreement must be completed to enroll in the Plan, to make changes to an existing Participation Agreement or to modify the
amount of your deferral.
To designate a beneficiary or change a beneficiary designation, apply for benefit payments/withdrawals, or transfer to/from other
plans or IRA’s, contact the Service Center at 1-800-584-6001 or visit www.CTdcp.com
Deferral
Amount
Complete this section only if you are enrolling or changing your deferral amount (including any Catch-up contributions).
Any amounts deferred must be made through payroll deductions from future compensation only. Deferrals made on a pre-tax
basis are not subject to state, federal or local income tax when made.
Deferrals can also be made on an after-tax basis. You can use a combination of pre-tax and post-tax deferrals as long as
you do not exceed the annual contribution limits.
Consult your Plan Registered Representative (Registered Representative) regarding restrictions that may apply if you
participate in any other salary reduction plan, such as a 403(b) plan or a 401(k) plan.
Unless you specifically elect and use one of the available Catch-up provisions, the maximum you can defer in any calendar
year is the amount specified under § 457(c) and § 457(e) (15) of the Internal Revenue Code (as adjusted for cost-of-
living). Your Registered Representative can explain the limitations applicable to your situation; however, it is ultimately
your responsibility to make sure that you do not defer more than is allowed in any calendar year.
The effective date of any enrollment or change of deferral amount cannot be earlier than the first pay period following the month in
which this form is completed or the earliest date thereafter consistent with the Administrator’s processing requirements and § 457
of the Internal Revenue Code.
Catch-Up
Contribution
Election
Before you can make Catch-Up contributions, you must first elect a Normal Retirement Age. Under the State of Connecticut
Deferred Compensation 457 Plan “Normal Retirement Age” is age 70 ½. However, you can elect an alternate Normal Retirement
Age that is on or after the earlier of: (i) age 65 or (ii) the earliest date you will become eligible to retire and receive immediate,
unreduced benefits under the defined benefit plan or the Alternate Retirement Program in which you also participate. The Normal
Retirement Age you select cannot be earlier than age 40 or later than 70 ½. This is a one-time election and cannot be changed.
The Special § 457(b) Catch-up option is available only during the three-year period before, but not including, the year in which you
will attain Normal Retirement Age. You cannot make these contributions unless you have underutilized prior year contributions
under the Plan. Complete the Special § 457(b) Catch-up Underutilization Worksheet to determine if you are eligible to use this
option.
The Age 50+ Catch-up contribution is available to those participants who are or will be at least age 50 by December 31st and who have
also elected to defer the maximum amount permitted under § 457(e)(15), as adjusted for cost-of-living.
Your Registered Representative can help you determine whether the Age 50+ Catch-up provision [under IRS regulation § 1.457-
4(c)(2)(i)] or the Special § 457(b) Catch-up Option [under IRS regulation § 1.457-4 (c)(2)(ii)] will provide the greater deferral amount.
You cannot use both the Special § 457(b) Catch-up and the Age 50+ Catch-up options during the same year. Consult with your
Registered Representative for further information.
Participant
Signature
Your signature acknowledges (1) receipt of the State of Connecticut Deferred Compensation § 457 Plan document and agreement to
the terms, provisions and conditions thereof; which terms, provisions and conditions are hereby incorporated into this Participation
Agreement and constitute your entire rights and obligations under the Plan; (2) that you have received and read an investment option
summary or a prospectus for each of the investment options you have elected to invest in; (3) that the State of Connecticut, your
Employing Agency and its agents are not required to invest deferred compensation in any manner whatsoever. You understand and
acknowledge that all Plan assets shall be held in trust by the trustee appointed by the Comptroller for the exclusive benefit of the
Participant in accordance with the Plan document and the Internal Revenue Code. You understand that participation in the State of
Connecticut Deferred Compensation § 457 Plan is voluntary. In return, you, your heirs, successors and assignees shall hold
harmless the State of Connecticut, its employees, officials, agents, assignees and successors from any and all liability for all acts in
good faith.
NOTE: THIS IS NOT A SAVINGS ACCOUNT.
THIS IS A DEFERRED COMPENSATION § 457 RETIREMENT PLAN.
Keep a copy of this Agreement for your records. Return the original signed form to your Registered Representative or to the address
shown on the front of this form.
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State of Connecticut - Form 457 Participation Agreement

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Completed 26 May 2020

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