Shubin Law Group - Web Book - Flipbook - Page 22
SHUBIN LAW GROUP 401(K) PLAN
Enrollment / Information Change Form
Shubin Law Group, P.A.
100 SE 2nd Street, Suite 4020
Miami, FL 33131
Certified Benefits Corp
1111 Douglas Avenue
Altamonte Springs, FL 32714
Please complete the following accurately. Print clearly.
SECTION 1: General Information
□
NEW ENROLLMENT
□
INFORMATION CHANGE
_______________________________________________________________________
Last Name
First Name
M.I.
_________-_________-_________
Social Security Number
_______________________________________________________________________
Mailing Address
(__________)________-________
Residence Telephone
_______________________________________________________________________
City
State
Zip Code
____________________________
Email Address
_____________________
Date of Birth (mm/dd/yy)
____________________
Date of Hire (mm/dd/yy)
□
YES, send my statement electronically
(please include email address for notification)
SECTION 2: Contribution Election (please select one of the options below)
❑
I want to make pre-tax salary deferral contributions to the Plan. I authorize my employer to deduct
$__________ or __________ .0% of my gross salary from each paycheck (not to exceed a total of $23,000
in 2014 if under the age of 50, or $30,500 in 2024 if age 50 or over) and to credit that amount to my pretax salary deferral portion of my account.
❑
I want to make post-tax (Roth 401(k)) salary deferral contributions to the Plan. I authorize my employer to
deduct $__________ or __________ .0% of my salary from each paycheck and to credit that amount to my
post-tax salary deferral portion of my account.
❑
I do not wish to contribute to the Plan at this time.
Signature – Please review to make sure that you have completed each accurately, fully, and legibly. Please return
this form to your employer for acceptance.
Employee Signature: __________________________________________Date: ___________________________
Employer Signature: __________________________________________Date: ___________________________