Paycheck Contribution Election
Governmental 457(b) Plan
Use black or blue ink when completing this form. For questions regarding this form, contact Service Provider at 1-866-737-7457.
98978-01 Commonwealth of Pennsylvania Deferred Compensation Program
A
A
Participant Information
Social Security Number
Account Extension (If applicable)
Last Name
Last Name
First Name
First Name
M.I.
M.I.
Street Address
Street Address
City
State
City
Email Address
State
B
City
Employee Number
Number
Employee
Email Address
Email Address
Payroll
Election(s)
B
O
i P
ll D d
Payroll Election(s)
Election
Zip Code
Zip Code
/
/
State
Zip Code
Date of Hire (mm/dd/yy)
Account extension identifies funds transferred to a
beneficiary due to death, alternate payee due to divorce
or a participant with multiple accounts.
/
Date of Birth /
(Date of) Birth
/
/
(Personal
) Phone Number
(Personal
) Phone Number
Work Phone Number
(
)
❑
Married
Unmarried
Work
Phone ❑
Number
(
)
Work Phone Number
Dept. of Employment (Ex. DPW, L & I, St. Police)
❑ Married ❑ Unmarried
/
/
/
/
Employee Number
Number
Date of
Agency
Employment
(Ex:DPW,
DPW,
I,St.
St.Polic
Police)
Employee
Dept.THAT
ofof
Employment
(Ex.
&&I, MADE.
PAYROLL
ELECTIONS MUST BE ENTERED INTO PRIOR
TOHire
THE(mm/dd/yy)
FIRST DAY OF THE MONTH
THE DEFERRAL
WILLL LBE
Employee Number
Number
Date of Hire (mm/dd/yy)
Employee
Dept. of Employment (Ex. DPW, L & I, St. Police)
i
Retirement
Date❑ StartMUST ❑
Select One:
PAYROLL
ELECTIONS
BERestart
ENTERED INTO
PRIOR TO ❑
THE
FIRST DAY OF THE MONTH THAT THE DEFERRAL WILL BE MADE.
Stop
❑ Change
Payroll
Deduction:
elect to
to contribute
contribute to
$ the Plan the following amount(s)
of my sick and
annual leave of
payout.
(An indication
of Whole
or Full will
not be
processed.)
(per
pay
period):
II elect
or percentage(s)
my eligible
compensation
as indicated
below
(PER
PAY
PERIOD):
Catch-UpPayroll
Provision
(if applicable)
Ongoing
Deductions:
Sick
and Annual
Leave MUST
Deduction
Only:
(PAYROLL
ELECTIONS
BE ENTERED
INTO PRIOR TO THE FIRST DAY OF THE MONTH THAT THE DEFERRAL WILL BE MADE.)
Retirement
Date❑ Start
Catch-Up
Provision
Utilized - If
eligible for❑
both
types of Catch-Up
Select
One:
❑ Stop this year, I may select either Age 50 §457 Catch-Up or Special §457 Catch❑I am
Restart
Change
Up,
whichever
would$result in the larger Catch-Up
forannual
this calendar
year. (An indication of Whole or Full will not be processed.)
elect
to contribute
contribute
of myamount
sick and
leave of
payout.
(per pay
period):
II elect
to
to the Plan the following amount(s)
or percentage(s)
my eligible compensation as indicated below (PER
PAY
PERIOD):
Age 50
Age
50 §457
§457 Catch-Up
Catch-Up -- II must
must be
be age
age 50
50 or
or older
older by
by the
the end
end of
of this
this calendar
calendar year
year and
and II may
may not
not use
use Special
Special §457
§457 Catch-Up
Catch-Up this
this year.
year. The
The total
total
before-tax
Before-Taxand
Contributions
$
or
%eligible
($5.00
- $17,000.00
or
- 100%)
$17,500.00
2014
before-tax
and
Roth Age
Catch-Up
exceed
compensation
in
2014
tax
Roth
Age 50
50 §457
§457
Catch-Up amount
amount cannot
cannot
exceed $5,500
$5,500 of
of my
my
eligible
compensation
in the
the.5%
2013
tax year.
year. When
When added
added to
to the
the
contribution
amount, the
the
aggregate maximum
maximum available
available
is $23,000
$23,000 of
of my
my eligible
eligible
compensation
in the
the
2014
tax
year.
basic
contribution amount,
is
compensation
in
year.
basic
Roth Contributions
$ aggregate
or
%
($5.00
- $17,000.00
or 2013
.5% -tax
100%)
$17,500.00
Catch-Up
-- II understand
the
$17,500
in

Special
§457
Catch-Up
understand
the total
total
Special §457
Catch-Up amount
amount
cannot
exceed
$17,500
of my
my eligible
eligible
compensation
in 2014.
2013.
D t cannot
f Hi exceed
(
/dd/
) of
/ compensation
/
P Special
llOne:
Eff §457
i D
(
/dd/
)
/ Special
/§457 Catch-Up
Retirement
Date
Select
❑ maximum
Stop
Start
❑ Restart amount,
❑ Change
When
to
basic
the
available
When added
added ❑
to the
the
basic contribution
contribution
amount,
the aggregate
aggregate
maximum
available is
is $35,000
$35,000 in
in 2014.
2013. II understand
understand that
that by
by electing
electing to
to begin
begin
elect
to contribute
contribute
$ the Plan
of my
and
annual
payout.
(An indication
Whole
or Full
notof:
be
processed.)
Special
§457
contributions,
shall
be sick
deemed
to
elect
as
Retirement
Age
the
earlier
(1)
the
calendar
year
(per
pay
period):
II elect
to
to
the following
amount(s)
or percentage(s)
of
my eligible
compensation
asyear
indicated
below
(PER
PAY
PERIOD):
Special
§457 Catch-Up
Catch-Up
contributions,
II shall
be
deemed
to
elect leave
as a
a Normal
Normal
Retirement
Ageof(NRA)
(NRA)
year
the will
earlier
of:
(1)
the
calendar
year in
in
which
rst contribution
which II reach
reach age
age 70
70 1/2,
1/2, or
or (2)
(2) the
the fourth
fourth calendar
calendar year
year from
from the
the date
date of
of the
thefiﬁrst
contribution under
under this
this Special
Special §457
§457 Catch-Up
Catch-Up election.
election. During
During
the
Before-Tax
Contributions
$ attained
or age
%
($5.00
- $17,000.00
or .5% - retirement
100%)
$17,500.00
to
for
benefits
the elected
elected NRA
NRA year,
year, II will
will have
have
attained the
the appropriate
appropriate
age and/or
and/or years
years of
of service
service
to be
be eligible
eligible
for unreduced
unreduced
retirement
beneﬁts under
under my
my
basic retirement
retirement plan.
plan.
NRA may
may not
not be
be changed
in
third
of
§457
Catch-Up.
II must
Employer’s
Roth Contributions
Employer’s
basic
NRA
changed
in my
my second
second and
and %
third year
year
of Special
§457 or
Catch-Up.
must have
have “underutilized
“underutilized
$
or
($5.00
-Special
$17,000.00
.5% - 100%)
$17,500.00
amounts”
by not
not contributing
contributing the
the maximum
maximum amount
amount available
to me
me under
under this
this Plan
Plan in
II was
amounts” by
available to
in any
any prior
prior calendar
calendar years
years in
in which
which
was eligible
eligible to
to
2014
D t forf Special
Hi ( §457
/dd/ Catch-Up
)
/
/
P participate.
llOne:
Eff Date
i II have
D
(calculated
/dd/ the
) total
/ ❑ IStop
Retirement
Select
have
calculated
total underutilized
amounts
participate.
underutilized
amounts
I have
have available
available for
Special §457
Catch-Up using
using the
the attached
attached underutilized
underutilized
❑
Start
❑ the
Restart
❑/ Change
amounts
worksheet
as
below,
have
attached
the
page
worksheet.
The
tools
are
provided
for
my
convenience
and
amounts
worksheet
as indicated
indicated
below, and
and
have
attached
the third
third
page
worksheet.
The calculation
calculation
are will
provided
for
my
convenience
elect
to contribute
contribute
$ the
of my
sick
and
annual
leave
payout.
(An indication
of Whole
or Full
not be
processed.)
(per
pay
period):
II elect
to
to
Plan
the following
amount(s)
or percentage(s)
of
my
eligible
compensation
astools
indicated
below
(PER
PAY
PERIOD): and
II should
tax advisor
advisor about
about my
my tax
tax situation.
situation.
should consult
consult with
with my
my tax
Before-Tax Contributions
$
or
%
($5.00 - $17,000.00
$17,500.00 or .5% - 100%)
Underutilized Amount: $_______________________

Roth
Contributions
$
or
%
($5.00
$17,000.00
$17,500.00 or .5% - 100%)
I elect to cancel my Catch-Up contribution election.
(mm/dd/yyyy)
/
/
Date
of
Hire
Payroll Effective Date (mm/dd/yyyy)
/
/
Payroll Deduction
Ongoing
Payroll Deductions:
Sick
and Annual
Leave MUST
Deduction
Only:
(PAYROLL
ELECTIONS
BE ENTERED
INTO PRIOR TO THE FIRST DAY OF THE MONTH THAT THE DEFERRAL WILL BE MADE.)
Retirement
Select
One:Date
This
election
will
all Restart
previous contribution
The total annual before-tax and Roth contributions combined cannot
❑ Stop
❑supersede
Start
❑
❑ Change elections.
exceed
of eligible
compensation
tax
year, unless
catch-up
provision
has
been
elected.
2014
elect to
to$17,500
contribute
$ the Plan
ofthe
my 2013
sick and
annual
leave of
payout.
(An
indication
of Whole
or Full will
not be
processed.)
(per
pay
period):
II elect
contribute
to
the followingin
amount(s)
or
percentage(s)
my eligible
compensation
as indicated
below
(PER
PAY
PERIOD):
Retirement
Date❑ Start
Select
One:
❑ Changeor ❑ Stop
Before-Tax Contributions ❑$ Restart
%
($5.00 - $17,000.00
$17,500.00 or .5% - 100%)
II elect
l
ib
$to the Plan the followingf amount(s)
i k dor percentage(s)
ll
to Contributions
contribute
of my eligible
compensation
as indicated
below ($5 or .5% minimum
Roth
$
or
%
($5.00
- $17,000.00
or .5% - 100%)
$17,500.00
contribution) (PER PAYCHECK):
Date of Hire (mm/dd/yyyy)
/
/
Payroll Effective Date (mm/dd/yyyy)
/
/
Retirement

Before-Tax
Contributions
$ Restart
or
%
Select
One:Date
❑ Stop
❑ Start
❑
❑ Change
$
elect
toContributions
contribute to
$ the Plan $the following amount(s)
of my sick and
annual leave of
payout.
(An indication
of Whole
or Full will
not be
processed.)

Rothto
or percentage(s)
%
(per
pay
period):
II elect
contribute
or
my eligible
compensation
as indicated
below
(PER
PAY
PERIOD):
Date
Payroll
EffectiveContributions
Date (mm/dd/yyyy)
/
Before-Tax
$
or /
%
($5.00 - $17,000.00
$17,500.00 or .5% - 100%)
I dd
t Contributions
ddthh t thLeave
l
l b f$ l bt f
d R thd R t h
ib or
ti ib i t
d $17 5
0
l Deduction:
Roth
($5.00 - $17,000.00
or .5% - 100%)
$17,500.00
Sick
and
Annual
Sick
and
Annual
Leave Deduction
(Will be forwarded
to your payroll %
department
for processing)
_____________
Retirement
Date Date
Payroll Effective
(mm/dd/yyyy)
/
/
I elect to contribute to the Plan the following amount(s) of my sick and annual leave payout: (An indication of Whole or Full will not be processed.)
I understand the total annual before-tax contributions cannot exceed $17,000.00 of my eligible compensation in the 2012 tax year.
Before-Tax Contributions $_________________
❑ Before-Tax Contributions $
or
%
($5.00 - $17,000.00 or .5% - 100%)
Roth Contributions
$_________________
Retirement
Select
D
t fOne:
Hi Date
( ❑
/dd/
)
/
/
❑ Stop
Startsick & annual
❑ Restart
❑ Change
Please Note: If the net
leave payout
amount is not sufﬁcient to attain the requested deferral amount, the deferral will be deducted
electthe
to ﬁcontribute
contribute
$ the Plan the following amount(s)
of my sick and
annual leave of
payout.
(An indication
of Whole
or Full will
not be
processed.)
(per
pay
period):
IIfrom
elect
to
to
or percentage(s)
my eligible
compensation
as indicated
below
(PER
PAY
PERIOD):
nal paycheck.
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98978-01
Last Name
C
First Name
MI
Social Security Number
Number
Participant Consent
My signature
signature acknowledges
acknowledgesthat
thatI have
I haveread,
read,
understand
and
agree
to pages
all pages
of the
Contribution
Election that
and Iaffirms
that all
My
understand
and
agree
to all
of this
formPaycheck
and afﬁrms
that all information
have provided
is
true and correct.
I alsoprovided
understand
that:and correct. I also understand that:
information
that I have
is true
M Until cancelled, superseded or I cease to be an eligible employee, this election 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.
M Payroll elections must be entered into prior to the first day of the month that the deferral will be made.
M I may change the dollar amount or percentage of compensation contributed as allowed under the terms of the Plan.
M 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.
M My Plan Administrator/Trustee 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.
M 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
D
Date (Required)
Mailing Instructions
Participant forward to Great-West Retirement Services®
Great-West Retirement Services® please retain this document for your records. Payroll elections are not maintained by Service
®
Great-West
Provider. Retirement Services
PO Box 173764
®
Great-West Retirement Services®
Denver, CO 80217-3764
301 Chestnut
St., Suite 402
Phone
#: 1-866-737-7457
Harrisburg,
PA
PA 17101
17101
Fax
#: 1-866-745-5766
Phone #: 1-866-737-7457
Fax #: 1-717-901-3620
Great-West FinancialSM refers to products and services provided by Great-West Life & Annuity Insurance Company (GWL&A), Corporate Headquarters:
Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York (GWL&A of NY), Home Office: White Plains, NY; its subsidiaries and
affiliates. The trademarks, logos, service marks, and design elements used are owned by GWL&A.
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Underutilized Amounts Worksheet for Special §457 Catch-Up
Begin with the first year you became eligible to participate in this Plan. Ignore all prior years.
Instructions:
1. Multiply your includible compensation by the percentage in column A, and enter this amount in column A (includible compensation).
a. For years prior to 2002, includible compensation is equivalent to the amount shown on the W-2 in Box 1 (or Box 10 for years prior to 1993).
b. For 2002 and thereafter, includible compensation is equivalent to the amounts shown on the W-2 in Box 1, PLUS any amounts received from your
employer as a qualified transportation fringe benefit, any amounts deferred under a §125 cafeteria plan and any contributions to a §401(k), §403(b)
and §457(b) plan.
2. In column C, enter the lesser of the amount in column A (includible compensation) or B (basic annual §457(b) contribution limit).
3. From column C, subtract columns D (actual contributions) and E (other contributions) and enter that amount in column F (underutilized amount).
4. Add totals from column F in the TOTAL UNDERUTILIZED AMOUNTS line at the end of the worksheet; this is your total underutilized amount.
5. You may only use an underutilized amount equal to the current year’s basic annual §457(b) contribution limit. Any remaining underutilized amount
may be contributed in any remaining special catch-up years, up to an amount equal to that year’s basic annual §457(b) contribution limit.
6. NRA may not be changed in your second and third year of catch-up and you must subtract the Special §457 Catch-Up amounts you contributed in a
prior year from the total underutilized amounts to determine your remaining underutilized amounts.
A
Calendar
Year
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
3
2012
B
Includible Compensation
(See instruction #1)
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
33.3% x $
100% x $
100% x $
100% x $
100% x $
100% x $
100% x $
100% x $
100% x $
100% x $
100% x $
100% x $
100% x $
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
C
Basic §457(b)
Contribution
Limit
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$7,500
$8,000
$8,000
$8,000
$8,500
$11,000
$12,000
$13,000
$14,000
$15,000
$15,500
$15,500
$16,500
$16,500
$16,500
$17,000
$17,500
$17,000
Total Underutilized Amounts (Column F)
Lesser of
A or B
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
D
E
F
Contributions to another 457(b),
Actual
403(b) or 401(k) for Years
Underutilized
Contributions to
Prior to 2002 and thereafter,
Amount
this 457(b) Plan
only to another §457(b)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Other 457(b) $
Other 457(b) $
Other 457(b) $
Other 457(b) $
Other 457(b) $
Other 457(b) $
Other 457(b) $
Other 457(b) $
Other 457(b) $
Other 457(b) $
Other 457(b) $
Other 457(b) $
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Prior Special §457 Catch-Up Contributions, if any (Column E)
-$
(subtract)
Total Underutilized Amounts Remaining
=$
(equals)
Great-West FinancialSM refers to products and services provided by Great-West Life & Annuity Insurance Company (GWL&A), Corporate Headquarters:
Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York (GWL&A of NY), Home Office: White Plains, NY; its subsidiaries and
affiliates. The trademarks, logos, service marks, and design elements used are owned by GWL&A.
A03:041012
STD FSALDF 7/10/14 Page 3 of 3
DACA/Manual (SR 870576)
A02:122112
][
JNEW/311880198
,JNEW/Manual
(SR 118800)
][