NACo Participation Agreement for 457(b) and 401(a) Plans

Transcription

1 ANationwide ' Personal Infmation 457(b) Employer Name 401(a) Employer Name Name ate of Birth Home Phone Number: NACo Participation Agreement f 457(b) and 401(a) Plans 457(b) Employer I 401(a) Employer I Social Security Number ate of Hire City, State, & ZIP Wk Phone Number: I Gender: [] Male [] Female How would you like to be contacted if additional infmation is required? [] Telephone [] Paperless elivery Consent Paperless elivery: By providing your address you are consenting to receive statements, confirmations, terms, agreements and other infmation 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 US Mailto the mailing address of recd by checking the box below, these documents will be made available to you electronically. [] I wish to receive my statements and account documents via US Mai]. Contribution Summary & PayrolIFrequency Contribution Amount - 457(b) Pre-Tax I $ Contribution Amount - 457(b) Roth '' I $ Contribution Amount - 401(a) Pre-Tax I Employee Mandaty Contributions'' I $ Total I $ Payro[[ Frequency: [] Weekly [] Other: [] Monthly ollar Amounts OR Percentages [] Semi-Month]y [] Bi-Week]y I NOTE: All increases. decreases and suspensions wil be implemented no sooner than the first payroll of the month following the change. Please remember to check your paystub to confirm your selected contributions are accurately reflected and being processed. Percentage contributions must be in whole percentages. Check with your employer on whether your plan offers deferrals in percentages. dollar amounts both :May not be offered by your plan. Roth contributions a re made on an after-tax basis. 'Employee Mandaty Contribution (401(a) only) is a one time election stated in the Plan ocument. This election is irrevocable and must be made befe the participant's first entry date Automatic Contribution Increase (This election is voluntary and is only available if permitted by your plan.) [] I wish to participate in an annua] automatic contribution increase. [] I wish to stop my annua] automatic contribution increase. Money Source ollar Amount Increase Percentage Increase 457(b) Pre-Tax $ 1 457(b) Roth l$ If selected, this increase will automatically occur annually as soon as administratively feasible f the date selected below. Increases can only occur f money source(s) (Pre-Tax and/ Roth) and mode(s) ($ ) that you are currently contributing. Please do not select a date of 02/29; if selected, Nationwide will Increase Contribution Annually on:.(mm/) process on 02/28 Additional infmation regarding the automatic contribution increase option can be found in the attached Memandum of Understanding. C-4641 (10/2016) F help, please cal1877-nrs-foru nrs to ru.co m

2 Beneficiary esignation [] Check here if this is a change of beneficiary. (Beneficiaries listed below replace any pri designation) PLEASE NOTE: Percentage split must total 100 f each categy of beneficiary. [f additiona] space f beneficiaries is required, attach additiona] sheets and mark this box: [] Additional infmation to assist you in completing your beneficiary designations can be found in the attached Memandum of Understanding. Primary Beneficiary(ies)(must total100): IPeiationship: jsociai Security #: Iphone # : I 1 split split split I Na«e: Relationship: Social Security # split: split Total = 100 Contingent Beneficiary(ies)(must total100) : split : I Relationship: Social Security # split : I Relationship Social Security # ate of Birth; split: : Relationship : Social Security # Relationship: Social Security # : split: Tatar'=100 2 C-4641 (10/2016) F help, please call 877-NRS-FORU nrsfu.com

3 ..... Funding Options Pre-tax and Roth contributions will use the same investment options and allocation. If you wish to have different selections, contact a Customer Service Representative at Nationwide ' Target estinatio11.series Nationwide8 estination 2015 Fund Nationwide8 estination 2020 Fund Nationwidee estination 2025 Fund Nationwide8 estination 2030 Fund Nationwide8 estination 2035 Fund Nationwides estination 2040 Fund Nationwide8 estination 2045 Fund Nationwides estination 2050 Fund Nationwide8 estination 2055 Fund Nationwides estination 2060 Fund Nationwide ' Invest estinations Series Nationwide; Invest estinations Aggressive Nationwides Invest estinations Moderate Aggressive Fund(Service Class) Nationwide8' Invest estinations Moderate Nationwide8 Invest estinations Moderate Conservative Fund(Service Class) Nationwide8 Invest estinations Conservative International American Century InternationaIiscovery Fund (Invest Classy American Funds - New Wlds" Fund (Class R4) Invesco International Growth Fund (Class R5) MFS InternationalValue Fund(Class R3)" Nationwide ' International Index Fund (Class A) Oppenheimer Global Fund (Class A) Nationwide ' Variable Insurance Trust: Nationwide Multi-Manager NVIT Small Company Fund (Class I) Nationwide ' SmallCap Index Fund(Class A) Nationwide ' SmallCompany Growth Fund Nationwide; U.S. SmallCap Value Fund Large Cap. American Century Growth Fund (Invest Class)" American Century Value Fund (Invest Class) American Funds - The Investment Company of America (Class A)" Edgar Lomax Value Fund Fidelity Contrafund '' Fidelity Equity-Income Fund Fidelity OTC Ptfolio ' Nationwide ' Fund Nationwidee Growth Fund Nationwide; Large Cap Growth Ptfolio Nationwides S&P 500 Index Fund Neuberger Berman Equity Trust Socially Responsive Fund (Invest Class) S&P 500 Index Fund (Class E) T. Rowe Price Growth Stock Fund (Advis Class) Invesco Growth & Income Fund (Class A) Balanced. Fidelity Puritan Fund Soecialtv Cohen & Steers Real Estate Securities Fund, Inc (Class A) Bonds MFS High Income Fund (Class Ay Nationwide; Bond Index Fund (Class A) Nationwide ' HighMark Bond Fund PIMCO Feign Bond Fund(U.S. ollar Hedged) PIMCO Total Return Fund (Class A) Waddell& Reed Advis High Income Fund (Class Y) Fixed/Cas Federated U.S. Government Securities Fund: 2-5 Years(InstitutionalShares) Invesco Sht Term Investment Trust Treasury Ptfolio(Institutional Class)" Nationwide: Government Money Market Fund (Invest Class) Nationwidez Fixed Account Mley Stable Value Retirement Fund ' 100 Totalf both columns must equal 100 Madcap. American Century Vista Fund (Invest Class) JP Mgan Mid Cap Value Fund (Class A). Nationwide ' iverse Managers Fund Nationwide; Mid Cap Market Index Fund (Class A). Neuberger Berman Equity Funds ' Genesis Fund (Trust Class). Wells Fargo Advantage Funds Fund (Administrat Class) iscovery This fund is a non-annuity fund and may not be available in your plan. Please contact the Public Sect Service Center at at NRS-FORU ( ) your local retirement specialist f details This fund may not be available in your plan. Please contact the Public Sect Service Center at NRS-FORU ( ) your local retirement specialist f details. C-4641 (10/2016) F help, please call 877-NRS-FORU nrsfu.com 3

4 Authization [] Please send me a copy of the Infmational Brochure/Prospectus(es) [] Please contact me regarding transferring my other pre-tax retirement plans [] Please send me fms regarding the Catch-Up Provision authize my Employer to make the contribution(s) to the Plan in the amounts I have designated above. The contribution(s) will continue until otherwise authized in accdance with the Plan. The withholding of my contribution(s) amount by my Employer and its payment to the designated investment option(s) will be reflected in the first pay period contingent on the processing of this application by the Public Sect Service Center in conjunction with the set-up time required by my payroll center. The contribution(s) is to be allocated to the funding options in the percentages indicated above. I understand some investment options may impose a sht-term trading fee. I understand I should read the fund prospectuses carefully. I have read and understand the terms contained in this fm, including the attached Memandum of Understanding, which is incpated herein. I accept these terms and understand that these terms do not cover all the details of the Plan products. Participant Signature: ate: Retirement Specialist Name(Print): Agent # Things To Remember Complete allof the sections on the Participation Agreement that apply to your request n n Remember to have the allocation of your funding options total 100, in whole percentages, when completing the Funding Options section. If allocations do not total100, the remaining amounts willbe considered to be not in good der, and you agree they willbe allocated to the Nationwide ' Money Market Fund(Prime Shares) F your beneficiary designation, the percentage split must total 100 f each categy of beneficiary. Complete the Authization section, and remember to sign and date this Participation Agreement Enclose the completed Participation Agreement, and any other documentation in the business reply envelope included with this booklet. Your Plan may permit you to contribute additional funds as a "catch-up" contribution during the last three years preceding the nmal retirement age under the Plan. If you would like to receive paperwk to take advantage of the catch-up provision, please check the appropriate box in the authization section on page four. Your employer willspecify the amount of 414(h) Pickup contributions(401(a) only). Generally. these contributions are expressed as a percentage of pay. If an amount is specified, alleligible employees are required as a condition of employment to make this contribution. Fm Return Mail Nationwide Retirement Solutions PO Box Columbus. OH Fax: Please note that the infmation provided on this Participation Agreement will supercede any pri infmation provided such as allocations, contribution amounts, contribution types (except Mandaty Employee Contribution) and/ beneficiary infmation. 4 C-4641(10/2016) F help, please call 877-NRS-FORU nrsfu.com

5 Nationwide Retirement: Solutions Payroll Authization Card (Please complete and submit to your Payroll; Center) 1. Personal Infmation Plan Infmation* P[an Type:]]457(b)[] 401(a)[] IRA Product (Check only ONE plan type. If you have several plan types, then Social Security Number ate of Birth gyou must submit a payroll authization card f each plan type.) Name Additional Action: [] InitialE] IncreaseE] ecrease]] Cancel Pre-tax contribution: $. Roth contribution: 0. (457(b) Plan Only) OLNEW. $..9 $. 'You may make both pre-tax and Roth contributions. Frequency:E] Bi-week]yE] Month]yE] Other Payroll eduction to begin on: (ate). city State epartment Participant Signature ate C ( )- Wk Phone Zip Code Original-Payroll Center Copy-Participant ICatch Up Provision Utilized':(select one option) [] Yes, 3-yearE] Yes, Age 50+E] No Nmal Retirement Age: Contact Nationwide: at NRS-FORU f further infmation on how catch up provisions wk. The earliest your enrollment contribution change can start is the first day of the month following your completed request. Please remember, your employer's processing schedule will determine the actual effective date of the contribution. It is the Plan Spons's/Pay Center's responsibility to ensure deferrals do not commence too early. I authize my employer to reduce my salary by the above amount f credit to my account with my employer's eferred Compensation Plan. This reduction will begin on the pay period specified above, but no sooner than is permitted by law than is lladministratively practicable. This reduction will continue until otherwise authized by my employer in accdance with the Plan