Walled Lake Consolidated School District

Walled Lake Consolidated School District

Eligible 457(b) Plan Election Form

Please read information on reverse side of form before signing.

I.Participant Information:

Name: ______Soc.Sec.# 999-99-_ _ _ _ Estimated Date of Retirement: ______

Present Annual Salary: ______Pay Periods Per Calendar Year: ______Date of Birth: ______

II.Contribution Information:(Please Check One)

____Initiate 457(b) salary reductionDeduct $ ______per pay beginning ______

____Change 457(b) salary reductionChange amount of 457(b) from $______to $______

beginning ______.

____Change Service ProviderPlease direct salary reduction service provider from

______to ______beginning ______

____ Stop 457(b) salary reductionDiscontinue salary reduction effective ______

____Utilizing catch-up provisions/special electionsMust be 50 or older during the year this election is made.

____In lieu of health(Date of birth must be provided above.)

This Agreement shall continue until the Employee completes another Participation Agreement either amending or terminating this Agreement or upon termination of employment.

III.Service Provider:

Financial Advisor/Agent Name: ______

List company you are directing your 457(b) contributions to: ______

IV.Agreement

The Employee is solely responsible for compliance with maximum limitations on contributions, including the limits under Section 457 of the IRC and related regulations. The Employee is hereby advised to consult his/her own financial or tax advisor before signing this Agreement. THE EMPLOYEE AGREES TO INDEMNIFY AND HOLD HARMLESS THE EMPLOYER FROM ANY CLAIMS, DEMANDS, JUDGMENTS, COSTS, OR EXPENSES (INCLUDING REASONABLE ATTORNEY’S FEES) ARISING OUT OF OR RELATING TO THIS AGREEMENT.

I, the Employee, understand that there may be IRS restrictions, limitations on contributions, and tax penalties on early withdrawals. I understand that before completing this Agreement, I should receive professional consultation outside the School District on such issues. I understand that this Agreement is legally binding, and the WalledLakeConsolidatedSchool District shall have no liability whatsoever for any loss or damages suffered by the Employee. I understand that I may change my elections at any time during the calendar year, but only on a prospective basis, and that my new elections will become EFFECTIVE ON THE FIRST DAY OF THE CALENDAR MONTH FOLLOWING THE MONTH IN WHICH THE PLAN ADMINISTRATOR RECEIVES AND ACCEPTS MY NEW ELECTION FORM. I further acknowledge and understand that WalledLakeConsolidatedSchool District’s sole responsibility is to transfer the above amounts to the product vendor and that I retain sole responsibility for decisions relating to the purchase, monitoring and sale of the investment product. I further acknowledge that I have received and read a copy of the Walled Lake Consolidated School District Eligible 457(b) Plan Document.

Participant Signature: ______Date Signed: ____/____/____

Plan Administrator Acceptance:

Received by: ______Date Received: ____/____/____

IMPORTANT: The WalledLakeConsolidatedSchool District eligible 457 plan document dated 01/01/03, and restated 01/01/06, which contains the rules governing the administration of the plan, is available upon request.

Revised: 12/02/05: 12/06