Central California Child Development Services, Inc. Retirement Savings Plan
601447 - 000
Enrollment/Change Form

Social Security Number:
 
Use this form only to designate your investment choices for future contributions. To transfer investment balances use the toll free number, if applicable, or contact your Plan Administrator.
You must complete a Beneficiary Designation Form.
 
Employee Information
First Name Initial Last Name
Street Address
City State ZIP
 
Date of Birth (MM/DD/YYYY) Date of Hire (MM/DD/YYYY) Married Status
 
Reason for Form
* If you elect to join the Plan and fail to make an investment choice election, or your elections do not total to 100% your contribution will be invested by the Plan's default. Please contact your Plan Administrator for specifics regarding your Plan's default investment choice.
 
Contribution Amount
Before-Tax Contributions:
I wish to contribute % of my eligible pay on a before-tax basis.
I do not wish to make before-tax contributions at this time.
I understand that IRS/Plan limits may affect the amount I can contribute to the Plan each year.
 
 
Catch-up Contributions
You may elect or change your Catch-up Contribution at any time. The effective date of your election is based on your Plan’s provisions. Other factors may also affect your Catch-up Contributions. Therefore, please read the Important Notes below before making an election.
I elect to contribute $ .00 per pay period as a Catch-up Contribution.
I elect to stop making Catch-up Contributions.
I do not wish to make Catch-up Contributions at this time.
I will not be at least age 50 by the end of the year.
 

* Important Notes:

  • If you exceed IRS/Plan limits (limits apply to the sum of before-tax or after-tax 401(k) contributions), the excess will be automatically re-characterized as Catch-up Contributions, up to the limit for Catch-up Contributions for the year.
  • With the exception of one-time deductions, your Catch-up Contribution election will carry over from year to year.
  • The investment mix of Catch-up Contributions will be the same as your regular contributions. The IRS/Plan limits may affect the amount you can contribute to the plan each year.
  • If you are making Catch-up Contributions but do not satisfy both the age and contribution requirements, your Catch-up Contributions will be re-characterized as regular contributions at the end of the year.

Central California Child Development Services, Inc. Retirement Savings Plan
601447 - 000
Enrollment/Change Form

Name: Social Security Number:
 
Investment Mix
Please invest my future Plan contributions in the Central California Child Development Services, Inc. Retirement Savings Plan as indicated below, in whole percentages.
 
 Asset Class  Investment Choice  Investment Choice Election %
Short Bonds/Stable/MMktTransamerica Stable Value Core Account %
Interm./Long-Term BondLoomis Sayles Investment Grade Bond Ret Acct %
Interm./Long-Term BondPIMCO Total Return Ret Acct %
Interm./Long-Term BondAllianceBernstein High Income Ret Acct %
Interm./Long-Term BondLord Abbett Total Return Ret Acct %
Interm./Long-Term BondAmerican Century Government Bond Ret Acct %
Interm./Long-Term BondPIMCO Real Return Ret Acct %
Aggressive BondsOppenheimer International Bond Ret Acct %
Large-Cap StocksBlackRock Equity Dividend Ret Acct %
Large-Cap StocksRidgeWorth Large Cap Value Equity Ret Acct %
Large-Cap StocksAmerican Funds Fundamental Investors Ret Acct %
Large-Cap StocksJPMorgan U.S. Equity Ret Acct %
Large-Cap StocksTransamerica Partners Stock Index Ret Acct %
Large-Cap StocksAmerican Funds Growth Fund of America Ret Acct %
Large-Cap StocksFidelity Advisor New Insights Ret Acct %
Large-Cap StocksMorgan Stanley Growth Ret Acct %
Small/Mid-Cap StocksRidgeWorth Mid-Cap Value Equity Ret Acct %
Small/Mid-Cap StocksFidelity Advisor Leveraged Company Stock Ret Acct %
Small/Mid-Cap StocksSSgA S&P Mid Cap Index Ret Acct %
Small/Mid-Cap StocksGoldman Sachs Mid-Cap Opportunities Ret Acct %
Small/Mid-Cap StocksNeuberger Berman Genesis Ret Acct %
Small/Mid-Cap StocksMorgan Stanley Growth Opportunities Ret Acct %
Small/Mid-Cap StocksVanguard Small-Cap Value Index Ret Acct %
Small/Mid-Cap StocksVanguard Small-Cap Growth Index Ret Acct %
Small/Mid-Cap StocksVanguard REIT Index Ret Acct %
International StocksAmerican Funds New Perspective Ret Acct %
International StocksAmerican Funds EuroPacific Growth Ret Acct %
International StocksThornburg International Value Ret Acct %
International StocksMFS International Value Ret Acct %
International StocksDFA Emerging Markets Portfolio Ret Acct %
Multi-Asset/OtherMFS Utilities Ret Acct %
Multi-Asset/OtherAmerican Funds Balanced Ret Acct %
Multi-Asset/OtherBlackRock Global Allocation Ret Acct %
Multi-Asset/OtherVanguard Target Retirement Income Ret Acct %
Multi-Asset/OtherVanguard Target Retirement 2010 Ret Acct %
Multi-Asset/OtherVanguard Target Retirement 2015 Ret Acct %
Multi-Asset/OtherVanguard Target Retirement 2020 Ret Acct %
Multi-Asset/OtherVanguard Target Retirement 2025 Ret Acct %
Multi-Asset/OtherVanguard Target Retirement 2030 Ret Acct %
Multi-Asset/OtherVanguard Target Retirement 2035 Ret Acct %
Multi-Asset/OtherVanguard Target Retirement 2040 Ret Acct %
Multi-Asset/OtherVanguard Target Retirement 2045 Ret Acct %
Multi-Asset/OtherVanguard Target Retirement 2050 Ret Acct %
Multi-Asset/OtherVanguard Target Retirement 2055 Ret Acct %
Multi-Asset/OtherVanguard LifeStrategy Income Ret Acct %
Multi-Asset/OtherVanguard LifeStrategy Conservative Growth Ret Acct %
Multi-Asset/OtherVanguard LifeStrategy Moderate Growth Ret Acct %
Multi-Asset/OtherVanguard LifeStrategy Growth Ret Acct %
  Total For All Investment Choices   %
 
After your initial enrollment in the Plan, to transfer existing plan account balances with Transmerica Retirement Solutions, do not use this form. Use the toll free number, if applicable, or contact your Plan Administrator. You must complete a Beneficiary Designation Form.
 
Authorization and Signature
I hereby authorize a payroll deduction of Plan contributions in accordance with the level(s) I have indicated. I understand this constitutes a "cash or deferred arrangement" under section 401(k) of the Internal Revenue Code and that my contributions are subject to the withdrawal restrictions of the Plan. By authorizing a payroll deduction, I understand I am electing to defer a portion of my salary to the Central California Child Development Services, Inc. Retirement Savings Plan. I understand that certain limitations are imposed on my contributions by Federal law and that my contributions may be refunded to comply with these laws. I further agree that neither Central California Child Development Services, Inc., the Plan Trustee, nor their affiliates will be liable for any loss when acting upon my instructions believed to be genuine.

I understand I have a duty to review my pay records (pay stub, etc.) to confirm the Plan Administrator has properly implemented my contribution election(s). Furthermore, I have a duty to inform the Plan Administrator in writing if I discover any discrepancy between my pay records and the election(s) I have made in this Enrollment/Change Form. I understand I may modify my deferral rate prospectively, at the time I notify Plan Administrator in writing, consistent with the Plan terms.



Employee Signature Date



Plan Administrator Signature Date

Once this form has been completed with all the necessary information and required signatures, please forward to the Processing center for processing. The form cannot be processed without Plan Administrator's signature

Mail To: Processing Center: 8488 Shepherd Farm Drive, West Chester, OH 45069   Fax No: (877) 449-4443
Central California Child Development Services, Inc. Retirement Savings Plan
601447 - 000
BENEFICIARY DESIGNATION FORM
Please Note: Beneficiary Form need only be completed if you are enrolling for the first time or making changes to your designated beneficiaries.

Name: Social Security Number:
You may name anyone you wish as your beneficiary. However, if you are married and you name someone other than your current spouse as beneficiary for all or part of the benefits payable, your spouse must consent to the beneficiary designation and complete the Spousal Consent section (it will need to be signed by your spouse and notarized). If your spouse does not complete this consent section, your beneficiary will be your spouse. Remember that changes in marital status may affect your beneficiary designations, so be sure to keep your designation current.

Unless you state otherwise, all primary beneficiaries will share equally and, if no primary beneficiary survives you, all contingent beneficiaries will share equally. If no beneficiary survives you, settlement will be made as provided in the Plan.
Beneficiary Designation
I name the following individual(s) to receive my Plan benefits in the event of my death in accordance with the terms of the Plan. This beneficiary designation cancels and replaces all prior designations and settlement agreements which I have made under the Plan. Benefits will be paid to my primary beneficiary(ies) if living. Benefits will be paid to my contingent beneficiary(ies) only if none of my primary beneficiaries are living.
Percentages below must equal 100% for Primary Beneficiary(ies).
-and-
Percentages below must also equal 100% for Contingent (Secondary) Beneficiary(ies) - if any.
Plan Beneficiaries
You must designate at least one Primary Beneficiary.
Primary    Contingent    Percentage
First Name Initial Last Name
Street Address Apartment No.
 - 
City State ZIP
- - / /
Social Security Number Date of Birth (MM/DD/YYYY) Relationship (Beneficiary is my _______________)
 
Primary    Contingent    Percentage
First Name Initial Last Name
Street Address Apartment No.
 - 
City State ZIP
- - / /
Social Security Number Date of Birth (MM/DD/YYYY) Relationship (Beneficiary is my _______________)
 
Primary    Contingent    Percentage
First Name Initial Last Name
Street Address Apartment No.
 - 
City State ZIP
- - / /
Social Security Number Date of Birth (MM/DD/YYYY) Relationship (Beneficiary is my _______________)
 
Central California Child Development Services, Inc. Retirement Savings Plan
601447 - 000
BENEFICIARY DESIGNATION FORM

Name: Social Security Number:
Beneficiary Designation Authorization and Signature




Participant Signature Signed at (City and State) Date




Spousal Consent
I, spouse of , hereby consent to the designation of the beneficiary(ies) named on this form. I understand that my spouse has designated someone other than (or in addition to) myself as a beneficiary to receive benefits under this Plan. I understand the financial impact of this designation. I also understand that my consent to this designation is irrevocable.

By signing below, I hereby waive all rights to the pre-retirement survivor benefit with respect to that portion of the Plan benefits payable to a beneficiary other than myself.




Spouse Name Spouse Signature Date

Notary Public or Plan Representative Signature Required

Subscribed and sworn to me before this__________________day of _____________, ____________




Signature State County