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50965-0621-EXPRESS457 1 MissionSquare Retirement Attn: Workflow Management Team P.O. Box 96220 Washington, DC 20090-6220 Toll Free [PHONE REDACTED] www.icmarc.org Fax (202) 682-6439 EMPLOYER PLAN NAME: FULL NAME: LAST, FIRST, MI MAILING ADDRESS: STREET CITY STATE ZIP 1 2 4 PERSONAL INFORMATION INVESTMENT SELECTION BENEFICIARY DESIGNATIONS • Carefully complete all sections of this form in blue or black ink. • Submit the completed form to your employer to enroll in the MissionSquare Retirement 457 Deferred Compensation Plan. By submitting this form, you understand you have not chosen an investment option. To select an investment option, log into www.icmarc.org/login once your account is established. If you do not select an investment option, you entire account will be invested in the Plan’s default investment selection. Once your account has been established, log in to your account at www.icmarc.org/login to setup your beneficiary designations. Specify the total percentage or dollar amounts you wish to contribute each pay period. Contributions will begin as soon as administratively possible following the month in which this form is submitted. Pre-tax contributions of % OR $ from my pay each pay period. Roth* contributions of % OR $ from my pay each pay period. *NOT available in all plans. Please check with your employer to confirm that Roth Contributions are offered in your plan before selecting this option. 3 CONTRIBUTION ELECTION DATE OF BIRTH: MM/DD/YYYY EMAIL ADDRESS: 457 Deferred Compensation Plans Express Enrollment form SOCIAL SECURITY NUMBER: PREFERRED PHONE NUMBER: 5 SIGNATURES Sign, date, and submit the completed form to your employer. Employee Signature: Date: MM/DD/YYYY Authorized Employer Official’s Signature: Date: MM/DD/YYYY Name and Title (Please Print): ICMA-RC is now EMPLOYER PLAN NUMBER: 30 MARITAL STATUS: Married Single GENDER: Male Female REHIRED? Check if yes DATE OF HIRE: MM/DD/YYYY PLEASE KEEP A COPY OF THE COMPLETED FORM FOR YOUR RECORDS. 6653 City of Cartersville