Jay Hauke.Draftline Enrollment - Web Book - 2025 - Flipbook - Page 21
Jay Hauke Payroll Incorporated 401(k) Plan
Enrollment / Information Change Form
Jay Hauke Payroll Incorporated
400 N. New York Ave., Suite 208
Winter Park, FL 32789
Certified Benefits Corp
1111 Douglas Avenue
Altamonte Springs, FL 32714
Please complete the following accurately. Print clearly.
SECTION 1: General Information
□
NEW ENROLLMENT
□ INFORMATION CHANGE
_______________________________________________________________________
Last Name
First Name
M.I.
_________-_________-_________
Social Security Number
_______________________________________________________________________
Mailing Address
_____________________
Date of Birth (mm/dd/yy)
_______________________________________________________________________
City
State
Zip Code
____________________
Date of Hire (mm/dd/yy)
(__________)__________-__________
Home Telephone
(__________)_________-__________
Mobile Phone [REQUIRED FOR SECURITY & ONLINE ACCESS]
_______________________________________________________________________
Email Address [REQUIRED FOR SECURITY & ONLINE ACCESS]
□ YES, send my statement electronically
(please include email address for notification)
SECTION 2: Contribution Election (please select one or more of the options below)
❑
I want to make pre-tax salary deferral contributions to the Plan. I authorize my employer to deduct
$__________ or _________ .0% of my gross salary from each paycheck and to credit that amount to my
pre-tax salary deferral portion of my account.
❑
I want to make post-tax (Roth 401(k) salary deferral contributions to the Plan. I authorize my employer to
deduct $__________ or __________ .0% of my salary from each paycheck and to credit that amount to my
post-tax salary deferral portion of my account.
Note: Contribution limits for 2025 not to exceed a total of $23,500 if under the age of 50, or $31,000 if age
50 or over. Also available to individuals aged 60, 61, 62, or 63 is The Super Catch-Up. This is NOT in
addition to the regular catch-up contribution. You can use either the regular catch-up limit ($7,500 in 2025)
OR the super catch-up limit ($11,250 in 2025), but not both.
❑
I do not wish to contribute to the Plan at this time.
Signature – Please review to make sure that you have completed each accurately, fully, and legibly. Please return
this form to your employer for acceptance.
Employee Signature: __________________________________________Date: ___________________________
Employer Signature: __________________________________________Date: ___________________________
