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457 DEFERRED COMPENSATION PLANS CONTRIBUTION FORM 1 PARTICIPANT INFORMATION 2 CONTRIBUTION AMOUNT & EFFECTIVE DATE 3 SIGNATURES Participant Signature Date: / / Employer Signature Date: / / ICMA-RC • Attn: Workflow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free [PHONE REDACTED] • www.icmarc.org • Fax [PHONE REDACTED] 49827-1118-360 REV 11/2020 Contribution Amount (per pay period) I authorize my employer to contribute the amount specified below from my pay each pay period, to be contributed to my 457 deferred compensation plan account with ICMA-RC. (Specify a percentage or dollar amount for pre-tax and/or Roth contributions.) Pre-Tax Contributions: Percentage: % or Dollar Amount: (per pay period) Roth Contributions: Percentage: % or Dollar Amount: (per pay period) Roth contributions are not available in all plans. Please check with your employer or ICMA-RC to confirm that Roth contributions are offered in your plan before selecting this option. Normal Contribution Limit (2021): 100% of compensation or $19,500, whichever is less. Catch-up Contributions: If you are taking advantage of either of the catch-up contribution provisions available to 457 plan participants, please check the applicable box below. Age 50 catch-up contributions (up to $6,500 more than the normal limit. $26,000 maximum.) Special pre-retirement catch-up (up to $19,500 more than the normal limit. $39,000 maximum.) Please read ICMA-RC’s Pre-Retirement Catch-Up Form for more information. Effective Date All contribution changes will be effective as of the first pay period of the calendar month following the date you submit this form to your employer, or as soon as administratively possible thereafter, unless a later date is specified below. • Future Effective Date (cannot be earlier than the beginning of the following month): / / 1. Use this form to initiate contributions to your 457 deferred compensation plan or change the amount of your after-tax contributions. Note: You should only use this form if you have previously established an account in your employer’s plan. 2. Return the completed form to your employer. Year Maximum Contribution Age-50 Catch-Up Pre-Retirement Catch-Up 2021 $19,500 (Approximately $750 every two weeks)* * If you are paid (24 pay periods per year), contribute $813 per pay period. $6,500 ($26,000 total) $19,500 ($39,000 total) Identification (Please provide your Social Security Number or Employee ID) Social Security Number: – – OR Employee ID: Employer Plan Number: Employer Plan Name: Full Name of Participant: SIGN