Retirement Investors’ Club
(RIC) 457/401a Plans
RIC Account Form
Look forward to retirement!!
Name
Social Security #
Last
Personal
Information
First
Birth Date
MI
Existing accounts use last 4 digits only
Agency/Dept
Employee ID #
Required for electronic submission only
Address
City
Phone (work)
State
Phone (home)
Zip
Phone (mobile)
Designate the deduction amount to send to your provider. The combined amount of all 457 pretax and Roth contributions in
a tax year is limited to the IRS annually declared maximum contribution limits (see https://das.iowa.gov/RIC/SOI/contributions).
457 Payroll
Deduction
Pretax
Changes affect
the 1st available
check of the
month following
receipt of this
form unless a
later date is
otherwise
indicated.
Provider
Changes
You must have
established an
account with
the receiving
provider to
complete a
transfer.
Roth (post-tax)
Deduction frequency
Horace Mann
$
/Check
$
/Check
 12 checks/yr -  1st or  2nd check
MassMutual
$
/Check
$
/Check
 24 checks/yr
TIAA-CREF
$
/Check
$
/Check
 26 checks/yr (all checks)
VALIC
$
/Check
$
/Check
Alternative effective date (if desired)
Voya*
$
/Check
$
/Check
 Begin as of
(check date)
Inactive Prov Exception
$
/Check
 1 check only
(check date)
 Final check
(check date)
Please transfer:
From:
To:
 100%
$












Horace Mann
MassMutual
TIAA-CREF
VALIC
Voya*
Security Benefit
Horace Mann
MassMutual
TIAA-CREF
VALIC
Voya*
Stop contributions to:
Redirect contributions to:










Horace Mann
MassMutual
TIAA-CREF
VALIC
Voya*
Horace Mann
MassMutual
TIAA-CREF
VALIC
Voya*
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.
Participant
Signature
X
Participant Signature
Date
Electronic submission FOR EXISTING ACCOUNTS ONLY. Include your name, the last
Fax to:
515-281-5102
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.
Form
Submission
• Click on the Submit button
Mail to:
DAS-HRE, Attn: RIC
1305 E. Walnut
Des Moines, IA 50319
Submit
• Scan/email this form to:
[email protected]
Agent Use Only (Not required for existing accounts or online provider enrollment)
I am authorized to open accounts for this employee and verify that he/she has established 457/401a accounts with the active provider shown below.
Print Agent Name
Agent Signature
Agent Phone Number
Received by RIC
*Formerly ING
Active Provider Name
Payroll Office
RIC Use Only
Date Received:
Date Pended:
Paycheck Effective Date:
Entered:
Name:
Checked:
Iowa Retirement Investors’ Club (RIC)  8 6 6 - 4 6 0 - 4 6 9 2  h t t p s : / / d a s . i o w a . g o v / R I C
CFN 552-0317
Revised 02/16/15
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