Paycheck Contribution Election Governmental 457(b) Plan

STD FSALDF 01/30/17 98978-01 MANUAL/DNLCND/3115574 04/07/17 Page 1 of 3 MANUAL/DAES/SR 3199288 Page 1 of 3 Paycheck Contribution Election Governmental...
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Paycheck Contribution Election Governmental 457(b) Plan Use black or blue ink when completing this form. For questions regarding this form, contact Service Provider at 1-866-737-7457.

98978-01 Commonwealth of Pennsylvania Deferred Compensation Program

A A

Participant Information

Social Security Number

Account Extension (If applicable)

Last Name Last Name

First Name First Name

M.I. M.I.

Street Address Street Address City

State

City Email Address

State

Zip Code

Zip Code / / State Zip Code Date of Hire (mm/dd/yy)

City Employee Number Number Employee Email Address

Account extension identifies funds transferred to a beneficiary due to death, alternate payee due to divorce or a participant with multiple accounts.

/ Date of Birth / (Date of) Birth

/ /

(Personal ) Phone Number (Personal ) Phone Number Work Phone Number ( ) ❑ Married Unmarried Work Phone ❑ Number ( ) Work Phone Number Dept. of Employment (Ex. DPW, L & I, St. Police)

❑ Married ❑ Unmarried / / / / Employee Number Number Date of (mm/dd/yy) Agency Employment (Ex: DPW, I,St. St.Polic Police) Agency of Employment Employee Dept. ofof Employment (Ex. DPW, &&I, MADE. PAYROLL ELECTIONS MUST BE ENTERED INTO PRIOR TOHire THE FIRST DAY OF THE MONTH THAT THE DEFERRAL WILLL LBE Employee Number Number Date of Hire (mm/dd/yy) Employee Dept. of Employment (Ex. DPW, L & I, St. Police)

B

Email Address Payroll Election(s)

B

O i P ll D d Payroll Election(s) Election

i

Retirement Date❑ StartMUST ❑ Select One: PAYROLL ELECTIONS BERestart ENTERED INTO PRIOR TO ❑ THE FIRST DAY OF THE MONTH THAT THE DEFERRAL WILL BE MADE. Stop ❑ Change Payroll elect to toDeduction: contribute to $ the Plan the following amount(s) of my sick and annual leave of payout. (An indication of Whole or Full will not be processed.) (per pay period): II elect contribute or percentage(s) my eligible compensation as indicated below (PER PAY PERIOD): Catch-UpPayroll Provision (if applicable) Ongoing Deductions: Sick and Annual Leave MUST Deduction Only: (PAYROLL ELECTIONS BE ENTERED INTO PRIOR TO THE FIRST DAY OF THE MONTH THAT THE DEFERRAL WILL BE MADE.)

Retirement Date❑ Start Catch-Up Provision Utilized - If eligible for❑ both types of Catch-Up Select One: ❑ Stop this year, I may select either Age 50 §457 Catch-Up or Special §457 Catch❑I am Restart Change Up, whichever would$result in the larger Catch-Up forannual this calendar year. (An indication of Whole or Full will not be processed.) II elect elect to contribute of myamount sick and leave of payout. (per pay period): to contribute to the Plan the following amount(s) or percentage(s) my eligible compensation as indicated below (PER PAY PERIOD): ‰ Age 50 §457 Catch-Up - I must be age 50 or older by the end of this calendar year and I may not use Special §457 Catch-Up this year. The total ‰ before-tax Before-Taxand Contributions $ or % ($5.00 $17,000.00 or .5% 100%) $17,500.00 2015 7 tax year. When added to the Roth Age 50 §457 Catch-Up amount cannot exceed $6,000 $5,500 of my eligible compensation in the 2016 2013 2015 contribution amount, the is $24,000 $23,000 of my eligible compensation in the 2013 year. ‰ basic Roth Contributions $ aggregate maximum available or % ($5.00 - $17,000.00 or2016 .5%7 -tax 100%) $17,500.00

$18,000 ‰ 2015. Catch-Up - I understand the total $17,500 compensation in 2016 2013. 7 D t cannot f Hi exceed ( /dd/ ) of my eligible / / P Special llOne: Eff §457 i D ( /dd/ ) / Special /§457 Catch-Up amount Retirement Date Select ❑ maximum Stop Start ❑ Restart amount, ❑ Change 2013. When added ❑ to the basic contribution the aggregate available is $35,000 $36,000 in 2016 2015. 7 I understand that by electing to begin elect to contribute contribute $ the Plan of my and annual payout. (An indication Whole or Full not of: be processed.) (per pay period): II elect to to the following amount(s) or percentage(s) of my eligible compensation asyear indicated below (PER PAY PERIOD): Special §457 Catch-Up contributions, I shall be sick deemed to elect leave as a Normal Retirement Ageof(NRA) the will earlier (1) the calendar year in which I reach age 70 1/2, or (2) the fourth calendar year from the date of the first contribution under this Special §457 Catch-Up election. During ‰ Before-Tax Contributions $ attained the appropriate or age and/or years of service % ($5.00 - $17,000.00 or .5% - retirement 100%) $17,500.00 to be eligible for unreduced benefits under my the elected NRA year, I will have ‰ Employer’s Roth Contributions basic retirement plan. NRA may not be changed in my second and % third year of -Special §457 or Catch-Up. I must have “underutilized $ or ($5.00 $17,000.00 .5% - 100%) $17,500.00 amounts” by not contributing the maximum amount available to me under this Plan in any prior calendar years in which I was eligible to D t f Hi ( /dd/ ) / / P llOne: Eff Date i I have D (calculated /dd/ the ) total underutilized / ❑ Stop Retirement Select I have available for Special §457 Catch-Up using the attached underutilized participate. amounts ❑ Start ❑ Restart ❑/ Change are will provided for my convenience amounts worksheet as indicated below, and have attached the third page worksheet. The calculation to $ the of my sick and annual leave payout. (An indication of Whole or Full not be processed.) II elect elect to contribute contribute to Plan the following amount(s) or percentage(s) of my eligible compensation astools indicated below (per pay period): (PER PAY PERIOD): and I should consult with my tax advisor about my tax situation. ‰ Before-Tax Contributions $ or % ($5.00 - $17,000.00 $17,500.00 or .5% - 100%) Underutilized Amount: $_______________________ ‰ Roth Contributions $ or % ($5.00 $17,000.00 $17,500.00 or .5% - 100%) ‰ I elect to cancel my Catch-Up contribution election. / / Date of Hire (mm/dd/yyyy) Payroll Effective Date (mm/dd/yyyy) / / Payroll Deduction Ongoing Payroll Deductions: Sick and Annual Leave MUST Deduction Only: (PAYROLL ELECTIONS BE ENTERED INTO PRIOR TO THE FIRST DAY OF THE MONTH THAT THE DEFERRAL WILL BE MADE.) Retirement Select One:Date This election will all Restart previous contribution The total annual before-tax and Roth contributions combined cannot ❑ Stop ❑supersede Start ❑ ❑ Change elections. 2015 exceed of eligible compensation the 2013 tax year, unless catch-up provision has been elected. $18,000 contribute $ the Plan of my 2016 sick7and annual leave of payout. (An indication of Whole or Full will not be processed.) II elect elect to to$17,500 contribute to the followingin amount(s) or percentage(s) my eligible compensation as indicated below (per pay period): (PER PAY PERIOD): Retirement Date❑ Start Select One: ❑ Changeor ❑ Stop ‰ Before-Tax Contributions ❑$ Restart % ($5.00 - $17,000.00 $17,500.00 or .5% - 100%) II elect l ib $to the Plan the followingf amount(s) i k dor percentage(s) ll to Contributions contribute of my eligible compensation as indicated below ($5 or .5% minimum ‰ Roth $ or % ($5.00 - $17,000.00 or .5% - 100%) $17,500.00 contribution) (PER PAYCHECK): / / Date of Hire (mm/dd/yyyy) Payroll Effective Date (mm/dd/yyyy) / / Retirement ‰ Before-Tax Contributions $ Restart or % Select One:Date ❑ Stop ❑ Start ❑ ❑ Change $ elect toContributions contribute to $ the Plan $the following amount(s) of my sick and annual leave of payout. (An indication of Whole or Full will not be processed.) ‰ Rothto or percentage(s) % (per pay period): II elect contribute or my eligible compensation as indicated below (PER PAY PERIOD): Date Payroll Effective Date (mm/dd/yyyy) / / ‰ Before-Tax Contributions $ or % ($5.00 - $17,000.00 $17,500.00 or .5% - 100%)

STD FSALDF 04/07/17 01/30/17

98978-01

MANUAL/DAES/SR 3199288 MANUAL/DNLCND/3115574 Page 1 of 3

98978-01 Last Name

C

First Name

MI

Social Security Number

Number

Participant Consent My signature signature acknowledges acknowledgesthat thatI have I haveread, read, understand and agree to pages all pages of the Contribution Election that and Iaffirms that all My understand and agree to all of this formPaycheck and affirms that all information have provided is true and correct. I alsoprovided understand that:and correct. I also understand that: information that I have is true

M M M M M

Until cancelled, superseded or I cease to be an eligible employee, this election shall apply to all eligible compensation allowed by the Plan paid from the effective date specified unless a different effective date is required under the terms of the Plan and cancels all previous elections. Payroll elections must be entered into prior to the first day of the month that the deferral will be made. I may change the dollar amount or percentage of compensation contributed as allowed under the terms of the Plan. It is my responsibility to comply with any Internal Revenue Code deferral limits and that I may be responsible for any costs, including taxes and penalties that I may incur as a result of excess contributions. My Plan Administrator/Trustee may take any action that may be necessary to ensure that my participation is in compliance with any applicable requirement of the Plan Document and the Internal Revenue Code. I authorize the payroll deduction as indicated on this form.

M Any person who presents false or fraudulent information is subject to criminal and civil penalties. Participant Signature

D

Date (Required)

Mailing Instructions Participant Retirement Participant forward forward to toEmpower Great-West Retirement Services® Great-West Retirement Services® please retain this document for your records. Payroll elections are not maintained by Service Empower Great-West Retirement Services® Provider.Retirement PO Box 173764 ® Great-West Retirement Services® Denver, CO 80217-3764 301 Chestnut St., Suite 402 Phone #: 1-866-737-7457 Harrisburg, PA PA 17101 17101 Fax #: 1-866-745-5766 Phone #: 1-866-737-7457 Fax #: 1-717-901-3620

Core Equities, Inc. and/or other broker dealers. Core securities, securities,when whenoffered, offered,are areoffered offeredthrough throughGWFS GWFS Equities, Inc. and/or other broker dealers. GWFS subsidiary of of Great-West Life & Annuity Insurance Company GWFS Equities, Equities,Inc., Inc.,Member MemberFINRA/SIPC, FINRA/SIPC,isisa awholly whollyowned owned subsidiary Great-West Life & Annuity Insurance Company. Empower Retirement refers the products services offered in retirement Annuity Insurance Company (GWL&A), Empower Retirementrefers refers to the products and services offered the retirement markets by Great-West Life & Annuity Insurance Company (GWL&A), Empower Retirement toto the products andand services offered in the markets by Great-West Life & Annuity Insurance Company (GWL&A),Corporate Corporate Headquarters: CO; Great-West & Annuity Insurance Company of New York, Office: White NY; and their NY,and NY; their Corporate Headquarters: Greenwood Village, CO; Great-West Life & Company Annuity Insurance Company New York, Home Of¿ce:Plains, Headquarters: GreenwoodGreenwood Village, CO; Village, Great-West Life & Annuity Life Insurance of New York, Home Of¿of ce: NY,Home NY; and their subsidiaries af¿and liates. All subsidiaries and All logos, service marks, andand design elements used are own their respective owners and are used permission. subsidiaries andaffiliates. af¿ liates. Alltrademarks, trademarks, logos, service marks, elements used areby owned by respective owners andbyare used by trademarks, logos, service marks, and design elements used are owned by design their respective owners and are used by their permission. permission.

STD FSALDF 04/07/17 01/30/17

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MANUAL/DAES/SR 3199288 MANUAL/DNLCND/3115574 Page 21 of 3

Underutilized Amounts Worksheet for Special §457 Catch-Up Begin with the first year you became eligible to participate in this Plan. Ignore all prior years. Instructions: your includible compensation in column A, and multiply by theA, percentage 1. Enter Multiply your includible compensation by the percentage in column and enter indicated. this amount in column A (includible compensation). a. For years prior to 2002, includible compensation is equivalent to the amount shown on the W-2 in Box 1 (or Box 10 for years prior to 1993). b. For 2002 and thereafter, includible compensation is equivalent to the amounts shown on the W-2 in Box 1, PLUS any amounts received from your employer as a qualified transportation fringe benefit, any amounts deferred under a §125 cafeteria plan and any contributions to a §401(k), §403(b) and §457(b) plan. applicable percentage) or B (basic annual §457(b) contribution limit 2. In column C, enter the lesser of the amount in column A (includible compensation compensation)xor B (basic annual §457(b) contribution limit). 3. From column C, subtract columns D (actual contributions) and E (other contributions) and enter that amount in column F (underutilized amount). 4. Add totals from column F in the TOTAL UNDERUTILIZED AMOUNTS line at the end of the worksheet; this is your total underutilized amount. 5. You may only use an underutilized amount equal to the current year’s basic annual §457(b) contribution limit. Any remaining underutilized amount may be contributed in any remaining special catch-up years, up to an amount equal to that year’s basic annual §457(b) contribution limit. 6. You NRAmust maysubtract not be changed in your second and amounts third yearcontributed of catch-upinand you year mustfrom subtract the Special §457 Catch-Up amounts youthe contributed the Special §457 Catch-Up a prior the total underutilized amounts to determine remainingin a underutilized amounts. prior year from the total underutilized amounts to determine your remaining underutilized amounts.

A Calendar Year 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2011 2012 2011 2012 2013 2011 2014 2012 2011 2015 2014 2012 2011 6 2015 2014 2012

Includible Compensation (See instruction #1)

B

C

Basic §457(b) Contribution Limit

33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 33.3% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $ 100% x $

$7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $8,000 $8,000 $8,000 $8,500 $11,000 $12,000 $13,000 $14,000 $15,000 $15,500 $15,500 $16,500 $16,500 $16,500 $16,500 $17,000 $16,500 $17,000 $17,500 $ , $16,500 $17,000 $17,500 , $16,500 $17,000 $17,500 $18,000 $16,500 $17,000 $17,500 $18,000

D

Lesser of A or B $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

E

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $ $ $ $ $ $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ Other 457(b) $ ( )$ Other 457(b) Other 457(b) ( )$ ( )$ Other 457(b) Other 457(b) ( )$ Other 457(b) $

Underutilized Amount $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$

Total Underutilized Amounts (Column F) Prior Special §457 Catch-Up Contributions, if any (Column E)

-$

(subtract)

Total Underutilized Amounts Remaining

=$

(equals)

STD FSALDF 04/07/17 01/30/17

F

Contributions to another 457(b), Actual Contributions 403(b) or 401(k) for Years to this 457(b) Plan Prior to 2002 and thereafter, only to another §457(b)

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