Simple Ira Salary Form – Fill Out and Use This PDF

SIMPLE IRA Plan Salary Reduction Agreement

Use this form to establish or change your SIMPLE IRA salary reduction election.

ompleted form should be returned to the employer and retained for the employer’s records. t return this form to Invesco Investment Services, Inc. (IIS).

PLEASE USE BLUE OR BLACK INK

PLEASE PRINT CLEARLY IN BLOCK CAPITAL LETTERS

1 | Participant Information

Full Name

Social Security Number	Date of Birth (mm/dd/yyyy)

Employer’s Name

2 | Salary Reduction Election (Select one.)

Subject to the requirements of the SIMPLE IRA plan of the above named employer.

I authorize % or $ , . to be withheld from my paycheck each period and contributed to my SIMPLE IRA as a salary reduction contribution.

I understand that the total amount of my salary reduction contributions in any calendar year cannot exceed the salary reduction contribution limits as prescribed by the Internal Revenue Service (IRS). (The IRS announces cost-of-living adjust- ments applicable to dollar limitations for pension plans annually.)

I elect not to participate in the SIMPLE IRA plan of the above named employer with respect to salary reduction contributions.

I elect to terminate my salary reduction contribution agreement under the SIMPLE IRA plan of the above named employer

effective. (Insert the date you want the salary reduction to stop.)

3 | Date Salary Reduction Begins

I understand that my salary reduction contributions will start as soon as permitted under the SIMPLE IRA plan and as soon as

administratively feasible or, if later

.

(Insert the date you want the salary reduction to begin. The date must be after you sign this agreement.)

4 | Employee Selection of Financial Institution

I select Invesco Trust Company (ITC) to serve as the custodian of my SIMPLE IRA. I understand that I must establish a SIMPLE IRA to receive any contributions made on my behalf under this SIMPLE IRA plan. If the information regarding my SIMPLE IRA is incomplete when I first submit my salary reduction agreement, I realize that it must be completed by the date contributions must be made under the SIMPLE IRA plan. If I fail to update my agreement to provide this information by that date, I under- stand that my employer may select a financial institution for my SIMPLE IRA.

5 | Duration of Election

This salary reduction agreement replaces any earlier agreement and will remain in effect as long as I remain an eligible employee under the SIMPLE IRA plan or until I provide my employer with a request to end my salary reduction contributions or provide a new salary reduction agreement as permitted under this SIMPLE IRA plan.

Participant’s Signature

Date (mm/dd/yyyy)

x

DO NOT SEND TO INVESCO – FOR COMPANY USE ONLY

IRA-FRM-11 12/20