CITY OF TRAVERSE CITY
Enrollment and Contribution Form
Use this worksheet to submit your employee information and/or any applicable contribution information elections to your
employer for enrollment in your CITY OF TRAVERSE CITY 457 Deferred Compensation Plan at MissionSquare Retirement.
I want to: Start My Journey: Join my CITY OF TRAVERSE CITY 457 Deferred Compensation Plan
Increase My Contributions
1. PERSONAL INFORMATION
PLAN SPONSOR NAME:
CITY OF TRAVERSE CITY 457 Deferred Compensation Plan 302250
SOCIAL SECURITY NUMBER: FOR TAX REPORTING PURPOSES DATE OF BIRTH: MM/DD/YYYY GENDER:
FEMALE MALE OTHER
FULL NAME: LAST, FIRST, MI MARITAL STATUS:
MARRIED SINGLE WIDOWED DIVORCED
MAILING ADDRESS:
STREET CITY STATE ZIP
MOBILE PHONE NUMBER: EMAIL ADDRESS: GO PAPERLESS:
*Choosing to go paperless means you are asking your employer to opt you into electronic communications to the email address you have designated.
2. CONTRIBUTION AMOUNT
I authorize my plan sponsor to contribute the amount specified below from my pay each pay period. Contributions will
begin as soon as administratively feasible under your plan.
Pre-tax contributions of ________% OR $_________ from my pay each pay period.
Normal Contribution Limit (2023): 100% of compensation or $22,500, whichever is less
Consider Ways to Save More:
Age 50 catch-up contributions (up to $7,500 more than the normal limit. $30,000 maximum)
457 Pre-Retirement Catch-up –SEE PRE-RETIREMENT CONTRIBUTION CATCH-UP FORM
3. INVESTMENT SELECTION
By submitting this form, you understand you are authorizing your plan sponsor to enroll you in the plan without
elections. Once your enrollment is processed you may log in to the participant website or mobile app to select your
investments. If you do not select an investment option, your entire account will be invested in the Plan’s default
investment selection.
4. BENEFICIARY DESIGNATION
Once your enrollment is processed you may log in to the participant website or mobile app to enter your beneficiary
information.
5. SIGNATURES (SIGN, DATE, AND SUBMIT THE COMPLETED FORM TO YOUR PLAN SPONSOR)
Employee Signature: __________________________________________________________ Date: MM/DD/YYYY ___________________________
Authorized Plan Sponsor Official’s Signature: _____________________________________ Date: MM/DD/YYYY ___________________________
Authorized Plan Sponsor Official’s Name and Title: ________________________________ Date: MM/DD/YYYY ___________________________
SUBMIT THE COMPLETED WORKSHEET TO YOUR PLAN SPONSOR. RETAIN A COPY FOR YOUR RECORDS.
For Plan Sponsor Use Only:
Employee ID:_________________________ Hire Date:MM/DD/YYYY ___________________________
Rehired? Check if Yes
Rehire Date:MM/DD/YYYY _____________________ Original Hire Date: MM/DD/YYYY _____________________ Leave Date:MM/DD/YYYY _____________________
