Get HI PTS Enrollment Form 2010

A copy of the PTS Deferred Compensation Retirement Plan Employee Information Booklet has been given to me. 5 of my gross wages shall be deducted from each paycheck and deposited into the PTS Deferred Compensation Retirement Plan. EMPLOYEE S SIGNATURE DATE. STATE OF HAWAII PTS DEFERRED COMPENSATION RETIREMENT PLAN for Part-Time Temporary and Seasonal/Casual Employees of the State Enrollment Form Please type or print in ink. RELATIONSHIP STATE ZIP SECTION III - OTHER EMPLOYMENT INFORMATION 1 Are you employed in any other State job s If YES with what department s a Do these other job s provide you membership in the State Employees Retirement System ERS q Yes q No 2 Are you an ERS retiree collecting monthly retirement benefits IMPORTANT If you answer YES to Questions 1a or 2 above be sure to notify your employer immediately to prevent problems with payroll deductions related to the PTS Deferred Compensation Retirement Plan. The Plan Booklet can be made available to individuals who have special needs or who need auxiliary aids for effective communication i.e. large print or audiotape as required by the Americans with Disabilities Act of 1990. Complete ALL information* Failure to complete and return this form may delay or prevent receiving your distribution check after you separate from service. Send your completed form to National Benefits Services LLC P. O. Box 6980 West Jordan UT 84084 SECTION I - IDENTIFYING/EMPLOYMENT INFORMATION NAME LAST FIRST MIDDLE INITIAL SOCIAL SECURITY NUMBER ADDRESS DEPARTMENT CITY STATE ZIP HI HOME PHONE DATE OF BIRTH qM q F DIVISION/SCHOOL POSITION TITLE S SECTION II - BENEFICIARY INFORMATION List person to whom you wish to leave your money in case of your death. For more information please call CFP/LSW at 596-7006 neighbor islands may call toll-free at 1-800-600-7167. SECTION IV - SIGNATURE Certification Section I certify that the above information is accurate. I understand that any incomplete/inaccurate information may result in back taxes and/or penalties imposed by the Internal Revenue Code. I understand that I will not contribute to Social Security but will contribute to Medicare. I understand that 7. Complete ALL information* Failure to complete and return this form may delay or prevent receiving your distribution check after you separate from service. Send your completed form to National Benefits Services LLC P. O. Box 6980 West Jordan UT 84084 SECTION I - IDENTIFYING/EMPLOYMENT INFORMATION NAME LAST FIRST MIDDLE INITIAL SOCIAL SECURITY NUMBER ADDRESS DEPARTMENT CITY STATE ZIP HI HOME PHONE DATE OF BIRTH qM q F DIVISION/SCHOOL POSITION TITLE S SECTION II - BENEFICIARY INFORMATION List person to whom you wish to leave your money in case of your death. For more information please call CFP/LSW at 596-7006 neighbor islands may call toll-free at 1-800-600-7167. SECTION IV - SIGNATURE Certification Section I certify that the above information is accurate. I understand that any incomplete/inaccurate information may result in back taxes and/or penalties imposed by the Internal Revenue Code. .