Central South Carpenters and Millwrights Defined Contribution Fund

SALARY DEFERRAL

INSTRUCTIONS: Employees who elect to have an amount deducted from their pre-taxable income may do so by using this form. Please keep a copy of the form for your records. (A copy will be emailed to you). This Salary Deferral will carry over to other signatory Employers. You may start, change, or stop a Salary Deferral ONLY during the open enrollment periods. (May 15 - June 15 and November 15 - December 15). Deferral elections made during open enrollment will go into effect on the first full pay period of the next month (July or January). Please use this form.

Employer

UBC No.

Local Union No.

Last Name

First Name

Middle Name

Home Address

City, State and Zip Code

Last four of SSN

Date of Birth

Telephone

Date of Hire

Start Change Stop

I hereby direct all signatory Employers to deduct the following amount from my pre-tax earnings each pay period. I understand this salary deferral is in addition to the non-elective contribution made to my account per the Collective Bargaining Agreement, or as required by other provisions. I also understand that I can only start, stop or change my salary deferral during the open enrollment periods.

Amount:

per hour

(50¢ increments to max of $8.00 per hour, i.e 0.50, 2.00, 5.50, etc)

Employee Signature:

Date

As with any investment, your contributions to this Fund involve risk. There is no guarantee that the funds you invest will grow, or that they will not decrease due to financial market conditions. The funds you invest in the 401K (salary deferral) feature are not insured by the FDIC or other government entity, and like any investment are subject to market fluctuations, including the possibility of actual loss.

(For your copy of the form)

CSCMDCF Deferral

Central South Carpenters and Millwrights Defined Contribution Fund

SALARY DEFERRAL