Retirement Enrollment

PERSONAL INFORMATION

Please complete this form in its entirety.

U.S. Citizen:

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

Sex:

Marital Status:

EMPLOYER

BENEFICIARIES

Primary Beneficiary

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

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)

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.

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 fund (must total 100%). If no choice is made, all funds will remain in the Default Fund.

Investment Options (See Prospectus for a description of Strategies)

Contribution Percentage

The Conservative Strategy

The Moderate Strategy

The Default Strategy

The Maximum Strategy

The Discipline Value Strategy

Total

CERTIFICATION

I am a salaried employee of a Free Will Baptist church or agency for at least 20 hours per week. 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.

Signature

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.

If you chose to enroll in the Group Term Life Insurance, please fill out the Retirement Plan Life Insurance Enrollment Form.

If you wish to have a portion of your salary withheld from your paycheck, please download and fill out the Salary Reduction Form