Retirement Investors’ Club (RIC)
457/401a Plans
RIC Account Form
Look forward to retirement!!
Name
Social Security #
Last
Personal
Information
First
Birth Date
MI
Agency/Dept
Employee ID #
Required for electronic submission only
Address
City
Telephone (work)
457 Payroll
Deduction
Deduction
changes affect
the 1st available
check of the
month following
receipt of this
form unless a
later date is
otherwise
indicated.
Transfers
Only
State
Telephone (home)
Zip
The combined amount of all 457 pretax and Roth (post-tax) elective contributions in a tax year is limited to the IRS maximum
contribution limit of $16,500 ($17,000 in 2012); $22,000 for persons age 50+ ($22,500 in 2012); and $33,000 if eligible for the 3
year catch-up ($34,000 in 2012).
Pretax
Roth (post-tax)
Deduction frequency
2nd check
$
/Check
$
/Check
12 checks/yr -
Horace Mann
$
/Check
$
/Check
24 checks/yr
ING
$
/Check
$
/Check
26 checks/yr (all checks)
Security Benefit
$
/Check
$
/Check
Alternative effective date
TIAA-CREF
$
/Check
$
/Check
Begin as of
(check date)
VALIC
$
/Check
$
/Check
1 check only
(check date)
Inactive Prov Exception
$
/Check
Final check
(check date)
Please transfer:
100%
$
From:
To:
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










Hartford
Horace Mann
ING
Security Benefit
TIAA-CREF
VALIC
Hartford
Horace Mann
ING
Security Benefit
TIAA-CREF
VALIC
Stop contributions to:
Redirect contributions to:












Hartford
Horace Mann
ING
Security Benefit
TIAA-CREF
VALIC
Hartford
Horace Mann
ING
Security Benefit
TIAA-CREF
VALIC
I understand and agree to the terms and conditions of the Retirement Investors’ Club (RIC). I have access to a Plan Summary and an
Investment Provider Summary. I understand that withdrawals may only be made upon termination of state employment, unless I apply
and am approved for an unforeseeable emergency withdrawal, a qualified cashout payment, or eligible service credit purchase.
X
Participant Signature
Form
Submission
1st or
Hartford
You must have
established an
account with the
receiving
provider to
complete a
transfer.
Participant
Signature
Existing accounts use last 4 digits only
Date
Electronic submission FOR EXISTING ACCOUNTS ONLY. Include your name, the
last four digits of your SS#, and employee ID# (signature not required). If you do not know
your employee ID#, contact your personnel assistant or RIC. You may submit 2 ways.
Submit
 Click on the Submit button
 Scan/email this form to:
[email protected]
Fax to:
515-281-5102
Mail to:
DAS-HRE, Attn: RIC
1305 E. Walnut
Des Moines, IA 50319
Agent Use Only (Not required for existing accounts or online provider enrollment)
I am authorized by
(active provider) to open accounts for this employee, who has established 457/401a accounts
with the provider.
Print Agent Name
Agent Signature
PA Use Only
Date Recvd:
CFN 552-0317
Revised 11/02/11
Agent Phone Number
Date
RIC Use Only
Pchk Eff Date:
Name:
Date Pended:
State of Iowa Retirement Investors’ Club (RIC)
(866) 460-4692 (toll free) / (515) 281-8677 / http://ric.iowa.gov/
Print
Reset
Entered:
Checked: