Retirement Enrollment

Personal Information

Please complete this form in its entirety.

U.S. Citizen(Required)

Are you an ordained minister or missionary? (If not, select N/A):(Required)

Gender(Required)

Marital Status(Required)

Name(Required)

First Middle Last

Date of Birth(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Day Phone(Required)

Work Phone(Required)

Social Security Number(Required)

Email Address(Required)

Employer

Employers Name(Required)

Job Title(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Church Treasurer / Payroll Administrator Name

Church Treasurer / Payroll Administrator Email

Beneficiaries

Primary Beneficiary

I designate the following as my primary beneficiary: (Must be spouse if married unless waiver is filed)

Name

First Middle Last

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code

Social Security Number

Relationship

Share Percentage %

If unmarried and would like to designate an additional primary beneficiary(ies), please provide their information below and indicate the percentage for each primary beneficiary.

Contingent Beneficiary(ies)

I designate the following as my contingent beneficiary(ies): (In the event the primary beneficiary is deceased, the contingent beneficiary(ies) will receive the funds in the account)

Name

First Middle Last

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code

Social Security

Relationship

Share Percentage %

Name

First Middle Last

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Social Security

Relationship

Share Percentage %

Name

First Middle Last

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code

Social Security

Relationship

Share Percentage %

Name

First Middle Last

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code

Social Security

Relationship

Share Percentage %

Term Life Insurance

Group term life insurance is available through Guardian Insurance Company for enrollees who are under 65 years of age. The Basic Term Life Coverage is $25,000 (for as long as you have a retirement plan with the Board of Retirement). The monthly premium of $16.50 is deducted from the contributions to your retirement account. For more information regarding this Group Term Life Insurance, please check out the Life Insurance section or view the Life Benefit Summary.

Term Life Insurance

Yes, I want this Group Term Life Insurance coverage. (Please fill out the Retirement Plan Life Insurance Form after submitting this application)

No, I do not want this Group Term Life Insurance coverage.

Investment Selection

You may invest in one or all investment options. Please indicate the percentage that you want invested in each option (must total 100%). If no choice is made, all funds will remain in the Default Strategy.

Investment Options (See Investment Plan Options for a description)

The Set Rate Fund*

The Moderate Strategy*

The Default Strategy*

The Maximum Strategy*

Large Cap Value

Large Cap Growth

All Cap Growth Equity

Intermediate Fixed Income

Short Term Fixed Income

Real Estate (REITs)

Total

Total should amount to 100%.

* Preset Plan with set allocations (For more information about Preset Plans, see Investment Plan Options)

Certification

I request that the Board of Retirement invest my accumulations/contributions based upon my investment choices above. I have reviewed the information provided by the Board of Retirement and I make this selection based upon my own investment judgement. I also realize that past results are not a guarantee of future performance. If I need additional information, I know that I can contact the Board of Retirement.

Date(Required)

Please enter todays date (mm/dd/yyyy)

Signature(Required)

Use your mouse (or finger if on a mobile device) to sign your name in the box below.

Referral

If you were referred to the Board of Retirement or heard about us at an event, please let us know in the box below.

Referral