Retirement Enrollment

Personal Information

Please complete this form in its entirety.

U.S. Citizen(Required)

Ordained minister or missionary? (If not, select N/A):(Required)

Gender(Required)

Marital Status(Required)

Full Name(Required)

First Middle Last

Date of Birth(Required)

Address(Required)

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

Primary Phone(Required)

Work Phone(Required)

Social Security Number(Required)

Email Address(Required)

Employer

Employer Name(Required)

Job Title(Required)

Employer 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 legally married unless waiver is filed)

Full Name(Required)

First Middle Last

Date of Birth(Required)

Address

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

Social Security Number(Required)

Relationship to you(Required)

Share Percentage %(Required)

If unmarried, you may choose to designate more than one (1) primary beneficiary; provide details below, indicating percentage for each.

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)

Full Name

First Middle Last

Date of Birth

Address

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

Social Security Number

Relationship to you

Share Percentage %

Full Name

First Middle Last

Date of Birth

Address

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

Social Security Number

Relationship to you

Share Percentage %

Full Name

First Middle Last

Date of Birth

Address

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

Social Security Number

Relationship to you

Share Percentage %

Full Name

First Middle Last

Date of Birth

Address

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

Social Security Number

Relationship to you

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 Group Term Life Insurance coverage; complete “Retirement Plan Life Insurance” application after submitting this enrollment..

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

Investment Selection

You may invest in one (1) or all investment options. Indicate desired percentage to invest in each option (must total 100%). If no choice is made, all funds 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 must equal 100%

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

Certification

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