Web Book 4PAWS 2024 - Ready - Flipbook - Page 19
4 PAWS HOUSE CALLS, LLC 401(K) PLAN
Enrollment / Information Change Form
4 Paws House Calls, LLC
700 Clay Street
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 UPDATE/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
❑
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 (not to exceed a total of $23,000
in 2024 if under the age of 50, or $30,500 in 2024 if age 50 or over) and to credit that amount to my pre-tax
salary deferral portion of my account.
❑
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: ___________________________
