457(b) SRA Form Fayette County

Fayette County 457(b) Employee Retirement Plan
New EnrollmentChangeNon-Participation Election: I elect not to participate in the 457(b) Employee Retirement Plan. I have been made aware of the Plan and choose to not participate at this time. I may change this choice and elect to participate in the Plan at a later time.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1.) I am requesting salary reduction to begin on paycheck date noted below:
Effective Date Of Salary Reduction*

MonthDayYear
Contribution Start Date
2.) Investment Custodian: Pershing 3.) Salary Reduction Amount - I request to defer the following amount from eligible compensation as an elective deferral in accordance with and subject to the IRS rules and regulations:
Pre-Tax Contributions which reduce my current taxable incomeAfter-Tax Roth Contribution which do not reduce my current taxable incomeBoth Pre-Tax Contribution and Roth Contributions
Pre-Tax Contributions

Pre-Tax Contributions reduce your current taxable income
Pre-Tax Contribution First Pay Period of Month as $:*
Enter Amount as $ (dollar amount) of my eligible compensation, per pay period
Pre-Tax Contribution Second Pay Period of Month as $:*
Enter Amount as $ (dollar amount) of my eligible compensation, per pay period
After-Tax Contributions

After-Tax Roth Contributions do not reduce your current taxable income
After-Tax Roth Contribution First Pay Period of Month as $:*
Enter Amount as $ (dollar amount) of my eligible compensation, per pay period
After-Tax Roth Contribution Second Pay Period of Month as $:*
Enter Amount as $ (dollar amount) of my eligible compensation, per pay period
I authorize Fayette County to remit the salary reduction amounts designated above to the designated investment company as contributions to the Fayette County 457(b) Employee Retirement Plan, an IRC §457(b) plan and I acknowledge the following:

• This agreement will take effect the month following the month in which the form is signed and dated below.
• This agreement will remain in effect until the employee notifies the Fayette County, in writing, to change or discontinue deferrals, or Fayette County terminates or modifies this agreement, at any time, to comply with applicable laws or for any other reason in its sole discretion.
• Fayette County does not warrant the performance or the appropriateness of any investment or the tax consequences and will not be responsible for any penalties or tax consequences resulting from this agreement.
• The Plan limits withdrawals, except after reaching age 73, while employed at Fayette County.
• I am aware of the fees and expenses charged by the designated investment company.

• I authorize Fayette County to release or obtain from my vendor any information that may be reasonably required to calculate contribution limits or to administer the Fayette County 457(b) Employee Retirement Plan.

• The Internal Revenue Service imposes various limits on contributions to, or benefits from, different retirement plans. In addition, some limits require aggregation of the Fayette County 457(b) Employee Retirement Plan with other plans in which I may participate. These rules may vary depending on the type of plan, the type of contributions, and how the plan is structured. Fayette County does not monitor your participation in other plans.
Non-Participation Election:

If Non-Participation Election is selected on this Agreement, I acknowledge:

I elect not to participate in the Fayette County 457(b) Employee Retirement Plan.

I understand that no Salary Reductions will be withheld from my compensation, that the Employer does not make contributions to the Plan, and that no benefits will accrue under this Plan.

I have been made aware of the Plan and choose not to participate at this time.

I may change my choice and elect to participate in the Plan at a later time.
INTERNAL REVENUE CODE CONTRIBUTION LIMITS
Annual Dollar Limit on Elective Deferrals (IRC §457(b)(2))
Internal Revenue Code (IRC) §457(b)(2) limits the amount of salary deferral contributions that can be contributed to the Winneshiek County 457(b) Employee Retirement Plan and to all IRC §457(b) plans and other similar type of plans in which an employee participates in any calendar year. The annual dollar limit is the lesser of 100 percent of the employee’s compensation for the calendar year, or the “applicable dollar amount”, which is $24,500 in 2026. An employee must self-monitor elective deferrals made to any other current or former employer retirement plans to avoid exceeding the IRC limits.

Age 50 or Older Catch-up Contributions (IRC §414(v)(2))
For participants aged 50 or older as of the end of the plan year, the current dollar limits on elective deferrals are increased. The additional elective deferrals that are permitted to be made by an eligible participant are the lesser of the participant’s compensation for the year, reduced by any other elective deferrals of the participant for the year, or the “applicable dollar amount”, which is $8,000 for 2026.

Special Ages 60, 61, 62, and 63 Catch-Up Limitation (IRC §414(v) as modified by SECURE Act 2.0, Section 109)

If the applicable Plan year is one where the Employee’s age is 60, age 61, age 62, or age 63, the current dollar limits on elective deferrals are increased. The additional elective deferrals that are permitted to be made by an eligible participant is the lesser of the participant’s compensation for the year reduced by any other elective deferrals of the participant for the year or the “applicable dollar amount” which is $11,250 for 2026.

Special 3-year Plan Catch-Up Limitation
If the applicable year is one of the Employee’s last 3 calendar years ending before the Participant attains Normal Retirement Age (Ages 55-70), the Employee may be eligible for additional deferrals. If electing the Special 3-year Plan Catch-Up Limitation, neither the Age 50 nor the Special Ages 60, 61, 62, or 63 limitations apply. Consult the Plan Representative or Plan Document for additional information.

Income Limits Apply to Pre-Tax Age 50 or Older Contributions and the Special 3-Year Plan Catch-up Election

If a Participant has FICA wages for the preceding year that exceed $145,000 from the Employer sponsoring the Plan, Age 50 or Older Contributions and Special 3-Year Plan Catch-Up limitations must be Roth Contributions. Section 603 of the SECURE 2.0 Act amends Code Section 414(v).

Fayette County cannot give tax advice. If you have questions about how tax law may affect your tax situation, please consult a tax advisor.
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Date*

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Date
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Fayette County 457(b) Employee Retirement Plan

Pre-Tax Contributions

After-Tax Contributions