3121_Beneficiary_SSA1945_fee Rev. 7.22.2009
Employer: □ New Enrollment □ Address Change □ Beneficiary Change
The Premier Plan
Eligible Full-Time, Part-Time, Seasonal, and Temporary Employees
Social Securit
Alternative Retirement Plan
Acknowledgement and Designation of Beneficiary Form
211 East Main Street, Suite 100, Lakeland, FL 33801
800.430.7999 ♦ Fax 863.686.9727 ♦ www.midamerica.biz
□ Name Change – Please insert former name here and fill in new name below. You must provide
documentation of proof of name change (ie. Copy of Marriage Certificate, Social Security Card, etc.).
Participant Information (please print legibly)
Name: Social Security #: Date of Birth: Male/Female
(Last, First)
Address:
(Street / PO Box) (Apt. #) (City, State Zip)
Daytime Phone: ( ) Evening Phone: ( ) Email:
Beginning (Hire Date) , I will participate in the (Employer) Deferred Compensation
Plan, IRC Section 457, and hereby forego my rights to receive compensation equal to
% of my eligible gross annual compensation in return
for the benefits provided thereunder. I wish this contribution to be invested in an annuity contract with American United Life. I understand that my
total amount of deferred compensation shall not exceed the lesser of the Section 415 dollar limit or 100% of the participant’s includable
compensation or such other sum as is permissible pursuant to the provisions of Section 457 of the Code in any calendar year. I understand that my
participating in this Plan is a condition of employment required by IRC Section 3121(b)(7) OBRA 1990. I further understand that payment(s) will be
based on the value of the individual account(s). I acknowledge that a copy of the Deferred Compensation Plan Document is available to me for my
review and understanding. The terms, conditions, and provisions of the Plan Document are hereby incorporated into this agreement.
Beneficiary Designations If you need more space than provided below, please attach an additional page.
Name: Social Security #: Date of Birth:
Primary
Address: Relationship: Percent:
Name: Social Security #: Date of Birth:
Contingent
Address: Relationship: Percent:
A $0.75 monthly fee will be applied to inactive participant account balances. Inactive participants are those participants who have not made a contribution to
the plan for one year, are no longer employed with this Employer, and who could, at any time, request a distribution of their account balance.
Statement Concerning Your Employment in a Job Not Covered by Social Security
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If
you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension
may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your
Social Security benefit amount may be affected.
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a
job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example,
if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of this provision is $313.50. This amount is updated annually. This
provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall Elimination
Provision.”
Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State
or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by
two-thirds of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social
Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500-$400=$100). Even if your
pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to
Social Security Publication, “Government Pension Offset.”
For More Information
Social Security Publications and additional information, including information about exceptions to each provision, are available at www.socialsecurity.gov
. You may also call
toll free 1-800-772-1213, or for the deaf or hard of hearing call the TTY number 1-800-325-0778 or contact your local Social Security office. Copies of the SSA-1945 are
available online at the Social Security website, www.socialsecurity.gov/form1945
. Paper copies can be requested by email at oplm.oswm.rqct.orders@ssa.gov or by fax at 410-
965-2037.
Form SSA-1945(12-2004)
Employee Signature Print Name Date
Submit completed form to:
MidAmerica Administrative & Retirement Solutions, Inc.
211 E Main Street, Suite 100, Lakeland, FL 33801
