Lump Sum Separation Pay Deferral Election Form: Fill out & sign online

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Click ‘Get Form’ to open the Lump Sum Separation Pay Deferral Election Form in the editor.
Begin by filling out Section I, Participant Information. Enter your Last Name, First Name, MI, Mailing Address, City, State, Zip Code, Daytime Telephone Number, Separation Date, and Alternate Contact Telephone Number.
Proceed to Section II, Contribution Information. In Part A, input the amounts you have contributed to each plan for the tax year you separate. Ensure you include all future payroll contributions as they impact your deferral limits.
In Part B of Section II, specify the amount you elect to contribute from your Lump Sum Separation Pay into your Savings Plus account. Make sure these amounts do not exceed annual contribution limits.
Complete Section III by certifying your request for contribution and signing the form. If applicable, attach your approved Savings Plus Catch-Up document.
Finally, save a copy for your records and submit the signed form to your personnel office at least five workdays prior to separation.

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