DEEMED ROTH IRA Participation Agreement

Transcription

1 The Kentucky Public Employees Deferred Compensation Authority 101 Sea Hero Road, Suite 110 Frankfort, KY or Toll Free Fax DEEMED ROTH IRA Participation Agreement Please print. Use only blue or black ink. Sign and date the bottom of the form and return to our office for processing. NEW ENROLLMENT AMENDMENT I. Personal Identification Data: 1. Social Security Number 2. Mr Mrs Ms Name (First) MI Last Suffix 3. Gender: ( ) Male ( ) Female 4. Date of Birth 5. Mailing address: (Street, P.O. Box, etc) New address? Yes [ ] 6. City: 7. State: 8. ZIP Code: 9. Home or cell phone #: 10. Work phone #: 11. Address: 12. Name of Your Employer: 13. Current hire date: 14a. # of Pay Periods per year: 14b. # of Billing Cycles per year (if different than 14a): 15.. Select only one (1) contribution method (A) Direct Pay (attach check) OR (B) After-Tax Payroll Deduction 16. Effective pay date: $ for tax year Amount per pay check $ (Minimum $100 per check) (Minimum $30 per Month) (For Authority use) 17a. Automatic Contribution Increase (This election is voluntary) If selected, this increase will automatically occur annually as soon as administratively feasible for the date selected below. Increases can only occur for money source(s) (Pre-Tax and/or Roth) and mode(s) ($ or %) that you are currently contributing. c I wish to participate in an annual automatic contribution increase. Money Source Dollar Amount Increase Percentage Increase 457(b) Pre-Tax 401(k) Pre-Tax c I wish to stop my annual automatic contribution increase. II. Selection of Investment Options: I understand that with Mutual Funds there is no guarantee of principal. Also, no assurance can be provided that the objective of any Mutual Fund will be attained or will not change, as there is some uncertainty in every investment. 17b. Please indicate below your fund choice(s). Enter the percent of your contribution amount that you choose to have invested in each fund(s). Keep fund elections as my current 401(k) plan elections Each Plan selected must total 100%. % FUND % FUND Fixed Contract Fund - 3 ^ Vanguard Mid-Cap Index Instl Aberdeen Emerging Markets Inst * Vanguard Small-Cap Index Instl American Europac Growth R6 * ** Vanguard Target Ret Inc Instl AMG GWK Small Cap Equity Instl Vanguard Target Ret 2010 Instl DFA International Small Co I * Vanguard Target Ret 2015 Instl Dodge & Cox International * Vanguard Target Ret 2020 Instl Federated US Gov Sec 2-5 Yrs * Vanguard Target Ret 2025 Instl Fidelity Contrafund Vanguard Target Ret 2030 Instl Fidelity Growth Co Vanguard Target Ret 2035 Instl Franklin High Income Fund R6 Vanguard Target Ret 2040 Instl Ivy Core Equity Fund Vanguard Target Ret 2045 Instl MetWest Total Return Bond Fund Vanguard Target Ret 2050 Instl PIMCO All Asset Fund Instl Vanguard Target Ret 2055 Instl Invesco Government & Agency Portfolio Vanguard Target Ret 2060 Instl T Rowe Price Instl Mid-Cap Eq Gr ** Vanguard Tot Bond Mkt Instl Vanguard Infla Prot Sec Instl Vanguard Tot Int l Stk Idx Signal Vanguard Instl Index Vanguard Wellington Admiral ^ Balances in the Fixed Contract Fund-3 are restricted from being moved directly into Invesco Government & Agency Portfolio or Federated US Govt. Securities Fund 2-5 Yrs. * These funds are designated as restricted funds and thereby limited to four (4) trades (purchases or sales) per rolling 30-day period per restricted fund. Failure to adhere to these limits may result in additional trading restrictions. ** This fund imposes a Purchase Block. -OVER-

2 III. Authorization for After-Tax Payroll Deduction (Complete this section only if you have elected contribution method B above in #15 and your employer has agreed to withhold your contribution from your paycheck.) I hereby authorize my employer to make the following payroll deduction $ per pay effective with the pay date of It is your sole responsibility to ensure you do not make excess contributions to IRA(s), including deemed IRA(s). Any contributions made during the calendar year will be treated as contributed solely for that calendar year. To the extent you desire to have contributions that are made between January 1 and April 15 treated as contributions for a prior tax year, such contributions must be made by direct pay. Employee Name (print) SS# - - Deductions are made without regard to any future changes in taxes; no partial deductions or carry overs to future pay periods will be made. This deduction will continue until changed in accordance with 401(k) Plan/IRA procedures. IV. Authorization of Participation: By my signature below, I hereby acknowledge that I have received, read and understand the information on the reverse side of this form. By signing below, I certify that I have reviewed and approve the accuracy of the information contained in this form and hereby elect the contributions indicated above. I understand that if I elect the Direct Pay option, for the first 7 days, my initial IRA contribution will be invested in the designated safe fund then automatically moved to the investment option(s) elected in Section II above. DATE ENTERED PAY FREQUENCY PAYER CODE 18. Employee s signature 19. Date signed 20. Accepted by: 21. Agent Code

3 I have received, read and understand the Deemed IRA Summary/Highlights Brochure, Deemed IRA disclosure statement and any applicable product Disclosure Statement(s) including Prospectus(es); and that the provisions and fees of the Deemed IRA have been explained to me. I understand that a copy of the Plan Document(s), which includes the Deemed IRA, is available from the Authority upon my request. I understand that the Plan and the above named documents are specifically incorporated herein by reference. I hereby agree to be bound by the terms of the 401(k) Plan/Deemed IRA and designate my Beneficiary(ies) as listed separately on the latest 401(k) Beneficiary Designation Form. I understand that the initial, any Amendment or Termination of my IRA Participation Agreement may be effective only as of the first pay day administratively practicable. I hereby authorize the Authority Staff and its agents to assist me in filling out this form at my direction. I acknowledge this assistance is an administrative service only and such service does not constitute investment advice. NRM-9684KY-KY

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5 DEPARTMENT OF THE TREASURY INTERNAL REVENUE SERVICE WASHINGTON, D.C TAX EXEMPT AND GOVERNMENT ENTITIES ' DIVISION, JUN O Commonwealth of Kentucky Kentucky Public Employees' Deferred Compensation Authority 105 Sea Hero Road, Suite 1 Frankfort, KY EIN Number: Ladies and Gentlemen: In a letter dated May 20, 2005, as supplemented by letters dated December 15, 2005, January 26, April 11, and May 25, 2006, your authorized representative requested a written notice of approval that the Commonwealth of Kentucky may serve as a nonbank trustee for deemed individual retirement accounts (IRAs) under a qualified employer plan described in section 408(q) of the Internal Revenue Code (Code). Section 408( q) of the Code provides, in pertinent part, that if a qualified employer plan elects to allow employees to make voluntary employee contributions to a separate account established under the plan, and, under the terms of the qualified employer plan, such account meets the applicable requirements of section 408 or section 408A for an IRA, then such account shall be treated for purposes of this title [Title 26] in the same manner as an individual retirement plan and not as a qualified employer plan (and contributions to such account or annuity as contributions to an individual retirement plan and not to the qualified employer plan) Section 7701 (a)(37)(a) of the Code defines an individual retirement plan as an individual retirement account (IRA) described in section 408. Section 408(a)(2) of the Code requires that the trustee of an IRA be a bank (as defined in section 408(n)) or such other person who demonstrates to the satisfaction of the Secretary that the manner in which such other person will administer the IRA will be consistent with the requirements of section 408. The Income Tax Regulations at section (e) contain the requirements that such other person must comply with in order to act as trustee for purposes of section 408 of the Code. However, pursuant to Temporary Regulation section T(e)(8},

6 2 Commonwealth of Kentucky notwithstanding the requirement of section (e)(1) of the regulations that a person must demonstrate by written application that the requirements of paragraphs (e)(2) through ( e )(6) of that section will be met in order to qualify as a non bank trustee, a governmental unit within the meaning of section T(e)(8) that demonstrates it possesses taxing authority under applicable law need not demonstrate that it satisfies the net worth requirements of section (e)(5)(ii) of the regulations. Based on all the information submitted to this office and all the representations made in the application, we have concluded that the Commonwealth of Kentucky, a sovereign state of the United States with taxing authority, is exempt from the net worth requirements of section (e)(5)(ii) of the regulations but otherwise meets the requirements of sections (e)(2) through (e)(6) and T(e)(8) of the regulations and, therefore, is approved to serve as a nonbank trustee for deemed IRAs under a qualified employer plan described in section 408(q) of the Code. The Commonwealth of, Kentucky may not act as a trustee unless it undertakes to act only under trust instruments that contain a provision to the effect that the grantor is to substitute another trustee upon notification by the Commissioner that such substitution is required because the Commonwealth of Kentucky has failed to comply with the requirements of section (e) of the regulations or is not keeping such records, or making such returns or rendering such statements as are required by forms or regulations. For example, one such form is Form 990-T for IRAs that have $1000 or more of unrelated business taxable income that is subject to tax by section 511(b)(1) of the Code. I The Commonwealth of Kentucky is required to notify the Commissioner of Internal Revenue, Attn: SE:T:EP:RA, Internal Revenue Service, Washington, D.C , in writing, of any change that affects the continuing accuracy of any representations made in its application. Further, the continued approval of the Commonwealth of Kentucky to serve as a nonbank trustee for deemed IRAs under a qualified employer plan described in section 408(q) of the Code is contingent upon the continued satisfaction of the criteria set forth in section (e) of the regulations. This approval letter is not transferable to any other entity. An entity that is a member of a controlled group of corporations, within the meaning of section 1563(a) of the Code, may not rely on an approval letter issued to another member of the same controlled group. Furthermore, any entity that goes through an acquisition, merger, consolidation or other type of reorganization may not necessarily be able to rely on the approval letter issued to such entity prior to the acquisition, merger, consolidation, or other type of reorganization. Such entity may have to apply for a new notice of approval in accordance with section ( e) of the regulations. This letter constitutes a notice that the Commonwealth of Kentucky may serve as a nonbank trustee for deemed IRAs under a qualified employer plan described in section

7 3 Commonwealth of Kentucky 408(q) of the Code and does not bear upon its capacity to act as a trustee or custodian under any other applicable law. This is not an endorsement of any investment or retirement plan. The Internal Revenue Service does not review or approve investments nor recommend retirement plans.. This notice of approval is effective as of the date of this letter and will remain in effect until withdrawn by the Commonwealth of Kentucky or revoked by the Service. This notice of approval does not authorize the Commonwealth of Kentucky to accept any fiduciary account before this notice becomes effective. In accordance with the power of attorney on file in this office, a copy of this letter is being sent to your authorized representative. If you have any questions, please contact Mr. Calvin Thompson (Badge No ) at (202) Sincerely, Carlton A. Watkins, Manager Employee Plans Technical Group 1 NRN-1378KY-0816

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