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Ase check the first box and enter $0. Per Pay Period. $ Multiply by number of pay periods to get annual contribution amount. Annual Amount. $ This amount will be divided by the # of pay periods per year (or the remaining # of pay periods). Other $ Use for unique situations - please explain. Please Explain "Other" Signature and Submission Information I agree to the above deferral request and will submit this form to my Employer for processing. I also aut.

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