To elect, change, or stop your
401(k) pre-tax contributions to your 401(k) account, submit this form to each
employer where you work or where you expect to work. It is your responsibility
to request 401(k) deductions from your paycheck from each employer, or to have
such deductions changed or stopped. Once
you submit your 401(k) Election Form to an employer, your election will remain
in effect with that employer even if you do not work for that employer for an
extended period of time and then return to work for him.
Your 401(k) Election Form is due:
July 31, October 31, January 31, or April 30 and will take effect within two
(2) payroll cycles following these due dates. You may elect to enroll or
revoke your contribution rate to be effective once per Plan Year (August
1 – July 31). You may change the amount of your 401(k) election once per
Plan Year Quarter.
__________________________________________________________________________________________
Address
City State Zip
__________________________________________________________________________________________
Telephone Number
Email Address (optional)
By signing this
agreement, I hereby request to enroll in, change or suspend my 401(k) pre-tax
contribution as follows until changed by me as provided under the terms of the
Plan:
¨ $0.00. (I revoke
my 401(k) election. I do not want
to contribute anymore.)
¨ $1.00 per straight time hour.
¨ $2.00 per straight time hour.
¨ $3.00 per straight time hour.
¨ $4.00 per straight time hour.
Notice:
401(k) contributions are not deducted from pay for any overtime work.
Name
of Employer/Contractor: _________________________________________________________
I acknowledge receipt of information regarding
my right to make employee 401(k) contributions to the Plan. I have reviewed my
401(k) election. The Plan permits me to defer compensation otherwise payable to
me, and have my employer contribute my deferred compensation to the Plan on my
behalf. I understand that my election will take effect as described in the formal
Plan. I understand that I must make elections for each employer where I work or
where I expect to work and such elections will remain permanent until changed
by me. I understand that I must submit a new form (or forms if you work for
more than one employer covered by the Plan) if I want to change or suspend my
401(k) contribution.
Original to Employer – Copy to
Employee – Copy to Local Union Office
If copy machine not available,
complete in duplicate.
If
you have any questions, contact the Pension Department at the Fund Office at
1-888-797-5261.