Form for Declining Retirement Plan Enrollment

Retirement Plan Decline Enrollment Form

To Decline Enrollment in the Plan, Complete this Form

Last 4 digits of Social Security #: *

Please enter NUMBERS ONLY. Do NOT use dashes (-) OR SPACES between numbers

Employee name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email address

I decline enrollment and have made no contribution elections *

I decline enrollment and have made no contribution elections

Employee's Signature *

Clear Signature

Date *