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STD FSALDF 09/22/25 95270-01 NO_GRPG / GU22 / MANUAL SR 03273389 / SR 16514403 Page 1 of 1 Paycheck Contribution Election 401(k) Plan PERSI Choice 401(k) Plan 95270-01 Use black or blue ink when completing this form. For questions regarding this form, visit the Web site at www.mypersi401k.com or contact Service Provider at 1-[PHONE REDACTED]. A Participant Information Account extension, if applicable, identifies funds transferred to a beneficiary due to participant's death, alternate payee due to divorce or a participant with multiple accounts. - - Account Extension Social Security Number (Must provide all 9 digits) Last Name First Name M.I. (The name provided MUST match the name on file with Service Provider.) Employer/Payroll Center ( ) Daytime Phone Number ( ) Alternate Phone Number B Payroll Election(s) Paycheck Contribution Election (Payroll Deductions) Select One: Start Restart Change Stop I elect to contribute to the Plan the following of my eligible compensation indicated below (per pay period): Select One: Start Restart Change Stop I elect to contribute to the Plan the following amount(s) or percentage(s) of my eligible compensation indicated below (per pay period): Before-Tax Contributions or ($1.00 - $31,000.00 or 1% - 100%) The total annual before-tax contributions cannot exceed $18,000.00 of my eligible compensation in the 2022 tax year. C Participant Consent (Please sign on the 'Participant Signature' line below.) My signature acknowledges that I have read, understand and agree to all pages of this form and affirms that all information that I have provided is true and correct. I also understand that: ●Until cancelled, superseded or I cease to be an eligible employee, all election(s) shall apply to all eligible compensation allowed by the Plan paid from the effective date specified unless a different effective date is required under the terms of the Plan and cancels all previous elections. ●I may change the amount of compensation contributed as allowed under the terms of the Plan. ●It is my responsibility to comply with any Internal Revenue Code deferral limits and that I may be responsible for any costs, including taxes and penalties that I may incur as a result of excess contributions. ●My Plan Administrator may take any action that may be necessary to ensure that my participation is in compliance with any applicable requirement of the Plan Document and the Internal Revenue Code. ●I authorize the payroll deduction as indicated on this form. Any person who presents false or fraudulent information is subject to criminal and civil penalties. Participant Signature Date (Required) A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay. D Mailing Instructions Participant forward this form to Employer Employer DO NOT send this form to Service Provider. Please retain for your records. NOTE: Fixed $ amount requires employer approval. Effective Pay Date: and do not send to PERSI. As of January 1, 2025, the annual contribution limit for 401(k) Plans is $23,500.00 ($31,000.00 if you are at least 50 years of age in 2025). If you contribute to both a 457 and 401(k) plan, you may contribute up to $23,500.00 ($31,000.00 if age 50) into each plan for a total of $47,000.00 ($62,000.00 if age 50). If you contribute to both a 403(b) and 401(k) plan, the combined annual contribution limit is $23,500.00 ($31,000.00 if age 50). Before-Tax Contributions or ($1.00 - $31,000.00 or 1% - 100%) or ($1.00 - $31,000.00 or 1% - 100%) Roth Election Contributions or ($1.00 - $31,000.00 or 1% - 100%) Securities, when presented, are offered and/or distributed by Empower Financial Services, Inc. (EFSI), Member FINRA/SIPC. EFSI is an affiliate of Empower Retirement, LLC; Empower Funds, Inc.; and registered investment adviser Empower Advisory Group, LLC. This material is for informational purposes only and is not intended to provide investment, legal or tax recommendations or advice.