403(b) Program Highlights - Henry Ford Health System
403(b) Program Highlights - Henry Ford Health System
403(b) Program Highlights - Henry Ford Health System
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<strong>403</strong>(b) <strong>Program</strong> <strong>Highlights</strong><br />
As part of <strong>Henry</strong> <strong>Ford</strong> <strong>Health</strong> <strong>System</strong>’s (HFHS)<br />
commitment to helping employees plan for<br />
their future financial wellness, HFHS offers a<br />
<strong>403</strong>(b) program whereby employees can save<br />
additional money for their future.<br />
What is the <strong>Henry</strong> <strong>Ford</strong> <strong>Health</strong> <strong>System</strong> <strong>403</strong>(b)<br />
<strong>Program</strong>?<br />
Because HFHS is a tax-exempt organization, HFHS<br />
can provide an opportunity for employees to<br />
participate in a <strong>403</strong>(b) <strong>Program</strong>. The program<br />
consists of employee contributions where employees<br />
may elect to defer a portion of their annual income on<br />
a before-tax basis “Traditional <strong>403</strong>(b)” or on an aftertax<br />
basis “Roth <strong>403</strong>(b).”<br />
Who can participate in the <strong>403</strong>(b) program?<br />
All employees can participate in the <strong>403</strong>(b) program.<br />
Investing in the program is another means of saving<br />
for retirement outside of the HFHS Retirement<br />
Savings Plan.<br />
What amount can employees contribute to<br />
their <strong>403</strong>(b) account each year?<br />
Employees determine the amount to contribute from<br />
each paycheck to their <strong>403</strong>(b) account. The<br />
maximum contribution amount for 2013 is $17,500 or<br />
$23,000 if the employee will be age 50 or older by<br />
December 31, 2013.<br />
The IRS mandates that the maximum contribution<br />
amounts shown above be reduced by contributions<br />
that were made to certain former employer retirement<br />
plans. Thus, if contributions were made to another<br />
employer’s retirement plan(s) during the same year<br />
the employee elects to contribute to the HFHS <strong>403</strong>(b)<br />
account, the employee may need to make sure that<br />
those contributions plus their HFHS <strong>403</strong>(b)<br />
contributions do not exceed the maximum amounts<br />
shown above. (see the <strong>403</strong>(b) Rules & Provisions<br />
section of the HFHS <strong>403</strong>(b) Election & Change Form<br />
located at www.henryfordconnect.com under HR<br />
Connect>Benefits>Retirement>HFHS <strong>403</strong>(b)<br />
Enrollment)<br />
What is the <strong>403</strong>(b) account enrollment<br />
process?<br />
1. Select MetLife Resources and/or Fidelity<br />
Investments as your <strong>403</strong>(b) provider.<br />
2. Establish a <strong>403</strong>(b) account with MetLife and/or<br />
Fidelity:<br />
a. If enrolling with MetLife, meet with a MetLife<br />
<strong>403</strong>(b) on-site representative to complete the<br />
required enrollment paperwork. To schedule an<br />
appointment, contact MetLife at 800-945-0840.<br />
b. If enrolling with Fidelity,<br />
i. Print out a Fidelity <strong>403</strong>(b) account application<br />
and HFHS <strong>403</strong>(b) Enrollment & Change form<br />
at www.henryfordconnect.com, select:<br />
HRCONNECT>Benefits>Retirement>HFHS <strong>403</strong>(b)<br />
Enrollment.<br />
ii. Complete and send the Fidelity application to<br />
the address listed on the application.<br />
iii. Contact Fidelity at 800-343-0860 to confirm<br />
that your <strong>403</strong>(b) account has been set up.<br />
iv. Once your <strong>403</strong>(b) account has been set up<br />
with Fidelity, complete the HFHS <strong>403</strong>(b)<br />
Election & Change Form and submit it to the<br />
HFHS Employee Services by fax at 313-874-<br />
6380 or employeeservices@hfhs.org.<br />
NOTE: Your contributions cannot commence until you<br />
have established a <strong>403</strong>(b) account with Fidelity<br />
Investments and/or MetLife Resources.<br />
Can employees change the per pay amount<br />
that they contribute?<br />
Employees can change their per pay deferral amount<br />
on line through HFHS self-service at<br />
www.henryfordconnect.com. Select HR Connect to<br />
access Sign in to Self-Service. Once you are signed<br />
in, select the My Benefits tab and then savings<br />
summary.<br />
IRS regulations allow an individual to start, stop,<br />
increase or reduce the contribution amount any time<br />
during the calendar year, as often as necessary.<br />
Questions? Go to www.henryfordconnect.com<br />
Select: HRCONNECT>Benefits>Retirement>HFHS <strong>403</strong>(b)<br />
Enrollment.<br />
2012Dec10
HFHS <strong>403</strong>(b) PROGRAM - 2013<br />
Election & Change Form and Rules & Provisions<br />
What is the <strong>Henry</strong> <strong>Ford</strong> <strong>Health</strong> <strong>System</strong> <strong>403</strong>(b) <strong>Program</strong>? Because <strong>Henry</strong> <strong>Ford</strong> <strong>Health</strong> <strong>System</strong> (HFHS) is a tax-exempt<br />
organization, HFHS can provide an opportunity for employees to participate in a <strong>403</strong>(b) <strong>Program</strong>. The program consists of<br />
employee contributions where employees may elect to defer a fixed dollar amount or a percentage of their annual income on<br />
a before-tax basis “Traditional <strong>403</strong>(b)” or on an after-tax basis “Roth <strong>403</strong>(b)”.<br />
Who is eligible to participate in the <strong>403</strong>(b) <strong>Program</strong>?<br />
With the exception of HAP employees and students, all employees are eligible to participate in the <strong>403</strong>(b) program,<br />
regardless of their employment status (i.e., full-time, part-time, house officer, temporary, union, etc.).<br />
When can employees enroll in the <strong>403</strong>(b) <strong>Program</strong>?<br />
Employees can enroll at any time during their employment with HFHS.<br />
What <strong>403</strong>(b) companies can HFHS employees invest with and who do employees contact?<br />
Fidelity Investments and/or MetLife Resources.<br />
Fidelity Investments: 800-343-0860 (Call this number for assistance with: a) completing the Fidelity <strong>403</strong>(b) Account<br />
Application for Plan #53014, b) fund selections, c) fund reallocations, d) fund performance, e) beneficiary changes, and f)<br />
distributions).<br />
Fidelity Investments: 800-642-7131 (Call this number to meet with a Fidelity representative to review your Fidelity accounts<br />
and develop an investment strategy).<br />
MetLife Resources: 800-543-2520 (Call this number for assistance with: a) fund reallocations, b) fund performance, c)<br />
beneficiary changes, and d) distributions).<br />
MetLife Resources: 800-945-0840 (Call this number to meet with a MetLife representative to: a) enroll in the <strong>403</strong>(b)<br />
program, b) review your MetLife accounts, and c) develop an investment strategy).<br />
What is the <strong>403</strong>(b) enrollment process?<br />
1. Select MetLife Resources and/or Fidelity Investments as your <strong>403</strong>(b) provider.<br />
2. Establish a <strong>403</strong>(b) account with MetLife and/or Fidelity:<br />
a. If enrolling with MetLife, meet with a MetLife <strong>403</strong>(b) on-site representative to complete their investment company<br />
account application and the HFHS <strong>403</strong>(b) Election & Change form. Contact MetLife at 800-945-0840 to schedule an<br />
appointment.<br />
b. If enrolling with Fidelity,<br />
i. Complete the attached Fidelity <strong>403</strong>(b) account application and send it to Fidelity at the address listed on the<br />
application, and<br />
ii. Contact Fidelity at 800-343-0860 to confirm that a <strong>403</strong>(b) account has been established for you.<br />
iii. Once your <strong>403</strong>(b) account has been established at Fidelity, complete the attached HFHS <strong>403</strong>(b) Election &<br />
Change Form and submit it to the HFHS Employee Services department by fax at 313-874-6380 or email at<br />
employeeservices@hfhs.org.<br />
NOTE: Employee <strong>403</strong>(b) contributions cannot commence until you have established a <strong>403</strong>(b) account with Fidelity<br />
Investments and/or MetLife Resources.<br />
What amount can employees contribute to their <strong>403</strong>(b) annually?<br />
Employees determine the amount from each paycheck to be contributed to their <strong>403</strong>(b) account not to exceed the maximum<br />
contribution amount of $17,500 or $23,000 if the employee will be age 50 or older by December 31, 2013.<br />
There are no employer “matching” <strong>403</strong>(b) contributions to either the Traditional or Roth <strong>403</strong>(b). Contributions consist of<br />
employee deferrals only.<br />
Reductions to maximum contribution limits:<br />
The IRS mandates that the employee must earn a certain gross annual pay in order to contribute the maximum to the<br />
program. For further details, see the HFHS Traditional & Roth <strong>403</strong>(b) Election Form and Rules & Provisions (Section “<strong>403</strong>(b)<br />
Contribution Limits” of page 1 of the election form).<br />
The IRS mandates that maximum contribution amounts be reduced by contributions that were made to certain former<br />
employer plans during the same year as your HFHS <strong>403</strong>(b) contributions. For further details, see the HFHS Traditional &<br />
Roth <strong>403</strong>(b) Election Form and Rules & Provisions document (Section 6.f. of the Rules & Provisions document)<br />
Can employees change the per pay amount that they contribute?<br />
Yes. Employees can change their per pay deferral amount on line through HFHS self-service at www.henryfordconnect.com.<br />
Once you access your self-service record, click on benefits home then savings summary.<br />
IRS regulations allow an individual to start, stop, increase or reduce the contribution amount any time during the calendar<br />
year, as often as necessary.<br />
Page 1 of 8<br />
2013Dec6
Do employees that contribute the maximum during the year need to complete a new election form to elect the<br />
maximum contribution amount for the following year?<br />
For employees who contribute the maximum amount during a payroll year and are actively participating in the Plan as of the<br />
first payroll period of the following year, HFHS will automatically change the contribution amount to the new annual limit.<br />
HFHS will prorate the annual limit amount, as a dollar amount per pay, based upon the new limit and the number of pay<br />
periods in the new payroll year.<br />
When can employees stop contributing to the <strong>403</strong>(b) <strong>Program</strong>?<br />
Employees can stop and restart their contributions at any time by completing a HFHS <strong>403</strong>(b) Election & Change Form (form<br />
attached).<br />
When can the funds be withdrawn from the <strong>403</strong>(b) account?<br />
The IRS rules state that the <strong>403</strong>(b) money saved is for retirement. If any funds are withdrawn under the hardship provision,<br />
the amount withdrawn is subject to normal income tax (Traditional <strong>403</strong>(b) only) and if the participant has not attained age 59<br />
1/2 at the time of withdrawal, an additional 10% penalty tax (Traditional and Roth <strong>403</strong>(b)) is applied. For further details,<br />
contact the customer service center for Fidelity Investments or MetLife Resources.<br />
Can employees change providers and their choice of investment funds during the year?<br />
Providers can be changed any time during the year by completing the HFHS <strong>403</strong>(b) Election & Change Form and the new<br />
investment company’s <strong>403</strong>(b) account application. Only the HFHS approved providers may be utilized. Contact Fidelity or<br />
MetLife directly.<br />
Employees can change their fund selection within a "family of funds" based on the provider’s rules. Fund changes are<br />
processed directly by MetLife and/or Fidelity.<br />
Can employees change deferrals between Traditional and Roth <strong>403</strong>(b)?<br />
Changes between Traditional and Roth <strong>403</strong>(b) deferral elections can be made at any time during the year by completing a<br />
HFHS <strong>403</strong>(b) Election Form. This form should be mailed or faxed to Employee Services at fax number 313-874-6380<br />
(phone: 855-874-7100).<br />
Do Fidelity Investments and MetLife Resources offer loans and hardship withdrawals?<br />
Fidelity Investments:<br />
Fidelity Loans: Does not offer loans. However, you should contact Fidelity to see if they did offer loans if you would have<br />
qualified for a loan. If Fidelity indicates that if they offered loans you would qualify for a loan, you can transfer the amount<br />
needed for the loan or your entire <strong>403</strong>(b) account balance from Fidelity Investments to MetLife Resources. Once this<br />
transfer is complete, you can file for a <strong>403</strong>(b) loan with MetLife. Your loan application will be filed directly with MetLife<br />
Resources. Call MetLife Resources at 800-945-0840 to find out the contact information for the MetLife on-site representative<br />
who services your work location. This representative can assist you with the loan process.<br />
Fidelity Hardship Withdrawal: You should contact the Fidelity Investments at 800-343-0860 to determine if you qualify for a<br />
hardship withdrawal. You must first exhaust your loan options in order to qualify for a hardship withdrawal. You can do this<br />
by transferring <strong>403</strong>(b) assets from Fidelity Investments to MetLife Resources (see directly above under Fidelity Loans). If<br />
Fidelity indicates that you qualify for a hardship withdrawal: 1) complete a Fidelity <strong>403</strong>(b) hardship withdrawal form (obtain<br />
form from Fidelity) and 2) obtain the IRS required support documentation (obtain a list from the HFHS <strong>403</strong>(b) Hardship<br />
Processing Center). Fidelity Investments (800-343-0860) or the HFHS <strong>403</strong>(b) Hardship Processing Center (888-649-4636)<br />
can provide you with information regarding the support documentation that is required by the IRS. Once both sets of<br />
documentation are complete, you can fax them to the HFHS <strong>403</strong>(b) Hardship Processing Center at 770-956-8780 or will<br />
submit them to the following address: HFHS <strong>403</strong>(b) Hardship Processing Center, 3003 Summit Blvd., Suite 100, Atlanta, GA<br />
30319-1468.<br />
MetLife Resources:<br />
MetLife Loans: Offers loans. You should contact the MetLife Resources customer service center at 800-543-2520 to<br />
determine if you qualify for a loan. If MetLife indicates that you qualify for a loan, complete a MetLife <strong>403</strong>(b) Loan form and<br />
submit it to MetLife for processing.<br />
MetLife Hardship Withdrawal: You should contact the MetLife Resources customer service center at 800-543-2520 to<br />
determine if you qualify for a hardship withdrawal. If MetLife indicates that you qualify for a hardship withdrawal: 1) complete<br />
the MetLife <strong>403</strong>(b) hardship withdrawal form, and 2) obtain the IRS required support documentation. MetLife Resources or<br />
the HFHS <strong>403</strong>(b) Hardship Processing Center can provide you with information regarding the support documentation that is<br />
required by the IRS. Once both sets of documentation are complete, you will submit them to the following address: HFHS<br />
<strong>403</strong>(b) Hardship Processing Center, 3003 Summit Blvd., Suite 100, Atlanta, GA 30319-1468. The HFHS <strong>403</strong>(b) Hardship<br />
Withdrawal Processing Center’s telephone number is (888-649-4636, at the prompt say “MetLife <strong>403</strong>(b) hardship”.<br />
For additional information regarding <strong>403</strong>(b) rules and regulations, review the <strong>403</strong>(b) Rules & Provisions portion of<br />
the <strong>Henry</strong> <strong>Ford</strong> <strong>Health</strong> <strong>System</strong> Tax Sheltered Annuity <strong>403</strong>(b) Election Form.<br />
Page 2 of 8<br />
2013Dec6
HFHS 2013 - <strong>403</strong>(b)<br />
Election & Change Form and Rules & Procedures<br />
<strong>403</strong>(b) Contribution Limits<br />
Employees who are enrolled in the HFHS Retirement Savings Plan, the maximum deduction for the year 2013 is:<br />
1) $17,500 for employees who earn a gross (all earnings) annual pay of $19,800 or greater, or<br />
2) 87% of gross pay for employees who earn a gross annual pay of less than $19,300 if under age 50 or $26,100 if<br />
age 50 or older by Dec 31 st (net pay after <strong>403</strong>(b) deduction must exceed minimum gross annual pay or the 88%<br />
will be automatically reduced)<br />
Employees who are NOT enrolled in the HFHS Retirement Savings Plan, the maximum deduction for the year 2013<br />
is:<br />
1) $17,500 for employees who earn a gross annual pay of $18,900 or greater, or<br />
2) 92% of gross pay for employees who earn a gross annual pay of less than $18,408 if under age 50 or $24,900 if<br />
age 50 or older by Dec 31 st (net pay after <strong>403</strong>(b) deduction must exceed minimum gross annual pay or the 92%<br />
will be automatically reduced)<br />
Employees who are or will be age 50 by December 31 st are eligible to contribute an additional amount (Age 50<br />
Extension). The maximum age 50 Extension amount for 2013 is $5,500.<br />
See attached Rules & Provisions page for additional <strong>403</strong>(b) rules and regulations.<br />
1. Employee Information<br />
Circle ONE: Mr. Ms. Dr. House Officer _________________<br />
Date of Birth<br />
______________________________________ ___________________ _________________<br />
Employee Name (first, middle initial, last) Social Security Number Employee I.D.<br />
__________________________________________ (_____)______________ (_____)____________<br />
Work Location (department name and location) Daytime Phone Fax Number<br />
2. Non-HFHS Employer Plan Contributions<br />
If during this year, you made contributions to any other employer’s (non-HFHS Plans) Retirement Plan(s) (i.e., defined in<br />
IRC Section <strong>403</strong>(b) (TSA), 401(k) (Cash or Deferred Arrangement), 401(k) (Roth Contributions), 408(k)(6) (SARSEP), or<br />
408(p) (SIMPLE)), enter the amount that you contributed to these plans below. See Item 6(g) on the attached Rules or call<br />
HFHS Employee Services if you have any questions. The IRS requires that the amount you contributed to a non-HFHS<br />
employer during this year will reduce the amount you can contribute to the HFHS <strong>403</strong>(b) program this year. The<br />
annual limit is an individual limit and applies to everyone equally (with the exception of the age 50 extension) regardless of<br />
the number of employers you have during any year.<br />
COMPLETE: $<br />
dollar amount contributed (contributions to a non-HFHS employer)<br />
(if zero, indicate NONE)<br />
3. Contribution Election - Payroll Effective Date(s)<br />
Select ONE Option (a or b):<br />
a) _______ () Next available pay period, OR b) _______ () Pay period beginning_______________<br />
(pay period begin date)<br />
Page 3 of 8<br />
2013Dec6
4. <strong>403</strong>(b) Salary Reduction Amount – COMPLETE 4A OR 4B (this election supersedes all<br />
prior elections)<br />
4A. Complete this section only if you are enrolling in the<br />
TRADITIONAL <strong>403</strong>(b) - (BEFORE-TAX CONTRIBUTIONS)<br />
TRADITIONAL <strong>403</strong>(b) – (BEFORE-TAX)<br />
Normal Elective Deferral Amount<br />
(complete a. b. OR c.)<br />
($17,500 withheld in the current payroll year)<br />
Enter per pay dollar amount. If electing to stop<br />
contributions, enter $0.00 on line b.<br />
a. □ () Check this box if you are electing the Annual<br />
maximum allowable deduction ($17,500).<br />
(your per pay deduction amount will be calculated by the<br />
HFHS Employee Services Department)<br />
b. $ Dollar amount deducted each pay<br />
period.<br />
Enter percent of pay to be deducted each pay<br />
period.<br />
TRADITIONAL <strong>403</strong>(b) – (BEFORE-TAX)<br />
Age 50 Extension Amount - Complete a & b<br />
<br />
Must be age 50 or older by the end of the<br />
calendar year in order to contribute an extra<br />
Age 50 deferral amount.<br />
c. % Percent of gross pay deducted each pay<br />
period.<br />
a. □ () Check this option if you elect to tax shelter an<br />
additional amount in the year 2013 representing the Age<br />
50 Extension. (You may make this election only if you<br />
are age 50 or older by the end of the 2013 calendar<br />
year.)<br />
b. $______________ Enter your total year 2013 Age 50<br />
Extension “annual contribution” amount. (Enter a dollar<br />
amount up to $5,500). Note: The per pay deduction<br />
amount will be calculated by Employee Services.<br />
4B. Complete this section only if you are enrolling in the<br />
ROTH <strong>403</strong>(b) – (AFTER-TAX CONTRIBUTIONS)<br />
ROTH <strong>403</strong>(b) – (AFTER-TAX)<br />
Normal Elective Deferral Amount -<br />
(Complete a, b OR c)<br />
($17,500 withheld in the current payroll year)<br />
Enter per pay dollar amount. If electing to stop<br />
contributions, enter $0.00 on line b.<br />
Enter percent of pay to be deducted each pay<br />
period.<br />
ROTH <strong>403</strong>(b) – (AFTER-TAX)<br />
Age 50 Extension Amount<br />
(Complete a & b)<br />
<br />
Must be age 50 or older by the end of the<br />
calendar year in order to contribute an extra<br />
Age 50 deferral amount.<br />
a. □ () Check this box if you are electing the Annual<br />
maximum allowable deduction ($17,500).<br />
(your per pay deduction amount will be calculated by the<br />
HFHS Employee Services Department)<br />
b. $ Dollar amount deducted each pay<br />
period,<br />
c. % Percent of gross pay deducted each pay<br />
period.<br />
a. □ () Check this option if you elect to tax shelter an<br />
additional amount in the year 2013 representing the Age<br />
50 Extension. (You may make this election only if you<br />
are age 50 or older by the end of the 2013 calendar<br />
year.)<br />
b. $______________ Enter your total year 2013 Age 50<br />
Extension “annual contribution” amount. (Enter a dollar<br />
amount up to $5,500). Note: The per pay deduction<br />
amount will be calculated by Employee Services.<br />
Page 4 of 8<br />
2013Dec6
5. <strong>403</strong>(b) Investment Company Election<br />
In this section, indicate the percent of your Salary Reduction Amount (amount indicated in Number 3, Section I of this form)<br />
to be invested with each investment company (must total 100%).<br />
I elect to have my Salary Reduction Amount invested with the following company(ies):<br />
Investment<br />
Percent of Salary Reduction Amount<br />
Companies<br />
Per Investment Company<br />
Fidelity<br />
MetLife<br />
_________%<br />
_________%<br />
TOTAL 100%<br />
I UNDERSTAND I MUST ALSO COMPLETE A SEPARATE <strong>403</strong>(B) INVESTMENT COMPANY APPLICATION(s) FOR ALL<br />
“NEW” COMPANIES THAT I HAVE ELECTED TO TAX SHELTER WITH Submit your <strong>403</strong>(b) investment company<br />
application directly to the investment company. Once you receive confirmation that your <strong>403</strong>(b) account has been<br />
established, mail the confirmation along with this HFHS Election form to:<br />
Employee Services, One <strong>Ford</strong> Place - 4E<br />
Phone: (855) 874-7100, Fax: (313) 874-6380<br />
6. Signatures<br />
Employee Section:<br />
I have read the attached Rules and Provisions of the HFHS <strong>403</strong>(b) <strong>Program</strong> and understand them and agree to be bound by<br />
them.<br />
I understand that HFHS shall have no liability for any loss attributable to my selection of an annuity product or custodial<br />
mutual fund or any specific investment fund offered.<br />
X<br />
Employee Signature<br />
Date<br />
Human Resources Service Center Section:<br />
Date Entered<br />
Pay Period Effective Date<br />
Date Received In H.R. Service Center<br />
Employee Services Representative Signature<br />
For additional information regarding <strong>403</strong>(b) rules and regulations, review the <strong>403</strong>(b) Rules & Provisions portion of this form.<br />
HFHS shall have no liability for any loss attributable to the Employee’s selection of an annuity product or custodial mutual fund or any<br />
specific investment fund offered.<br />
None of the investment options offered by <strong>403</strong>(b) <strong>Program</strong> companies Fidelity Investments or MetLife Resources should in any way be<br />
deemed as recommended by HFHS for investment. Neither HFHS nor the investment manager will guarantee any investment results.<br />
This document summarizes <strong>403</strong>(b) program provisions as clearly as possible. However, this form is not intended to summarize all <strong>403</strong>(b)<br />
provisions. The official <strong>403</strong>(b) <strong>Program</strong> Document remains the final authority. If this document is in conflict with the <strong>403</strong>(b) <strong>Program</strong><br />
Document, the respective official program document remains the final authority.<br />
The HFHS <strong>403</strong>(b) <strong>Program</strong> is governed by the terms and conditions of the official agreements that participants complete with Fidelity<br />
Investments and/or MetLife Resources and the HFHS <strong>403</strong>(b) enrollment form. If this document is in conflict with the official agreements,<br />
then the official agreements remain the final authority.<br />
In addition, similar to all HFHS benefit plans/programs, HFHS maintains the right to amend, modify or terminate the HFHS <strong>403</strong>(b) program<br />
at anytime.<br />
Page 5 of 8<br />
2013Dec6
RULES AND PROVISIONS OF THE<br />
HENRY FORD HEALTH SYSTEM (HFHS)<br />
<strong>403</strong>(b) PROGRAM<br />
1. In no event shall a salary reduction authorized by this Election exceed the legally permissible tax<br />
exclusion as may be permitted under Internal Revenue Code Sections 402(g), <strong>403</strong>(b) and 415(c).<br />
To the extent there needs to be a reduction of the contribution amount of this election, the<br />
reduction shall be made upon notice to the affected Employee.<br />
Salary reduction amounts “Normal Elective Deferral” shall in no event exceed $17,500 for<br />
the year 2013. Furthermore, by signing this Election the Employee understands the $17,500<br />
(normal elective deferral limit) will be adjusted if regulations so require, unless the Employee is<br />
eligible for the Age 50 Extension (up to an additional $5,500 deferral) deferral allowed for those<br />
individuals who will attain age 50 by the end of the year as described in Number 2 of this<br />
document.<br />
This Normal Elective Deferral election will continue to be in effect during the remainder of this<br />
payroll year unless and until a new Election Form is signed by the Employee. This Election will<br />
automatically be continued into the next payroll year, unless the Employee notifies HFHS in<br />
writing within thirty days prior to the date that the Employee wishes to have this Election either<br />
terminated or modified. For employees who contributed the maximum amount during a payroll<br />
year and are actively participating as of the first payroll period of the following year, HFHS will<br />
automatically change the contribution amount to the annual limit by prorating the new limit<br />
amount over the number of pay periods in the new payroll year.<br />
The 2013 limits for <strong>403</strong>(b) Elective Deferrals is $17,500. Any future increases will be based upon<br />
the cost of living.<br />
2. Employees who reach age 50 by the end of the year 2013, may be eligible to make an additional<br />
deferral of up to $5,500 in excess of the $17,500 limit. Thus, individuals electing the Age 50<br />
Extension may tax shelter up to $23,000 ($17,500 Normal Elective Deferral plus up to $5,500 Age<br />
50 Extension) in the year 2013.<br />
This year 2013 Age 50 Extension election of up to $5,500 will continue to be in effect during the<br />
remainder of this payroll year unless and until a new Election Form is signed by the Employee.<br />
This Election will automatically be continued into the next payroll year, unless the Employee<br />
notifies HFHS in writing within thirty days prior to the date that the Employee wishes to have this<br />
Election either terminated or modified.<br />
Page 6 of 8<br />
2013Dec6
3. Employees are allowed to make changes to their <strong>403</strong>(b) <strong>Program</strong> salary reduction amount<br />
(including the allocation of contributions between pre-tax and after-tax amounts) by completing a<br />
revised Election & Change Form or by making changes “online” using the HFHS “employee selfservice”<br />
feature at www.henryfordconnect.com. Employees acknowledge that they are fully<br />
responsible for any changes they process through a revised Election & Change Form or changes<br />
they process through employee self-service. Further, any changes they make by a subsequent<br />
Election Form or by using the online feature are subject to the Rules and Provisions of the HFHS<br />
<strong>403</strong>(b) <strong>Program</strong>.<br />
4. HFHS will apply the amount of the salary reduction described in Numbers 1 & 2 of this document<br />
to the purchase of a custodial mutual fund described in Section <strong>403</strong>(b)(7) of the Internal Revenue<br />
Code of 1986, as amended, from one or more underwriters authorized by the HFHS and selected<br />
by the Employee. The selection of an underwriter shall be made on the HENRY FORD HEALTH<br />
SYSTEM <strong>403</strong>(b) ELECTION form (attached) hereto and any subsequent change in said<br />
underwriter selection shall also be made on the HENRY FORD HEALTH SYSTEM <strong>403</strong>(b)<br />
ELECTION form.<br />
5. By hereby authorizing the HFHS to purchase, on the Employee’s behalf, a mutual fund held by a<br />
custodial bank, the Employee hereby accepts the provisions of the HFHS <strong>403</strong>(b) <strong>Program</strong>.<br />
6. Employee releases all rights present and future to receive from HFHS the amounts specified<br />
above.<br />
7. Employee understands and agrees that:<br />
a. HFHS shall have no liability whatsoever for any loss attributable to the Employee’s<br />
selection of an annuity product or custodial mutual fund or any specific investment fund<br />
offered thereunder.<br />
b. HFHS executes this voluntary Salary Reduction Agreement solely to provide the Employee<br />
with the opportunity to benefit from the provisions of IRC Section <strong>403</strong>(b) and nothing in this<br />
Agreement, expressed or implied, is intended to constitute an employer sponsored plan.<br />
c. An Employee’s participation hereunder shall be voluntary, including the ability to decide<br />
what if any portion of the contribution is made on an after tax basis to the Roth <strong>403</strong>(b).<br />
d. Any tax issues that may arise due to an Employee’s participation in this voluntary <strong>403</strong>(b)<br />
program shall solely be the responsibility of the Employee.<br />
e. All computations made in connection with the determination of the maximum amount the<br />
Employee can contribute to the IRC Section <strong>403</strong>(b) program shall be the sole responsibility<br />
of the Employee.<br />
Page 7 of 8<br />
2013Dec6
f. The Employee agrees to promptly notify HFHS of any elective contributions he/she makes<br />
to any other plan defined in [IRC Section <strong>403</strong>(b) (TSA), 401(k) (Cash or Deferred<br />
Arrangement, 408(k)(6) (SARSEP, or 408(p) SIMPLE, including Roth contributions to any<br />
of these programs)] which will reduce the maximum allowable elective deferrals that the<br />
employee can make during the calendar year. Employee confirms that he/she is aware<br />
that any elective contributions made to the HFHS <strong>403</strong>(b) program will be aggregated with<br />
any contributions made to a 401(a) qualified plan sponsored by a non-HFHS employer of<br />
which the Employee has a 50% or more ownership in for purposes of the maximum annual<br />
addition limitations of IRC Section 415 (the lesser of 100% of pay or $50,000) that apply to<br />
the non-HFHS employer Plan.<br />
g. The annual Normal Elective Deferral amount of $17,500 and the annual Age 50 Extension<br />
amount up to $5,500 referred to in Numbers 1 & 2 of this document will also be reduced by<br />
any previous elective deferrals during the year made by the Employee to any other <strong>403</strong>(b),<br />
401(k), 408(k)(6) or 408(p) plans. Employee states that the sum of these elective<br />
contributions for the current payroll year (including contributions at a previous employer)<br />
are disclosed in Number 4 of the Enrollment Form.<br />
h. If the amount chosen in Number 3, Sections I & II of the Enrollment Form is a dollar<br />
amount, the amount will be prorated over the remaining pay periods of the current year. If<br />
any subsequent change is made in the dollar amount, the increase or decrease shall be<br />
similarly prorated.<br />
8. This Agreement is legally binding and irrevocable with respect to amounts earned while it is in<br />
effect. Each party to the Agreement expressly reserves the right to terminate said Agreement<br />
upon giving thirty (30) days notice to the other party.<br />
9. No provision of this Agreement shall affect HFHS’s right to discharge the Employee, with or<br />
without cause.<br />
10. HFHS shall have no liability for any loss attributable to the Employee’s selection of an annuity<br />
product or custodial mutual fund or any specific investment fund offered.<br />
11. None of the investment options offered by <strong>403</strong>(b) <strong>Program</strong> companies Fidelity Investments or<br />
MetLife Resources should in any way be deemed as recommended by HFHS for investment.<br />
Neither HFHS nor the investment manager will guarantee any investment results.<br />
12. This document summarizes <strong>403</strong>(b) program provisions as clearly as possible. However, this<br />
document is not intended to summarize all <strong>403</strong>(b) provisions. The official <strong>403</strong>(b) <strong>Program</strong><br />
Document remains the final authority. If this document is in conflict with the <strong>403</strong>(b) <strong>Program</strong><br />
Document, the respective official program document remains the final authority.<br />
11. The HFHS <strong>403</strong>(b) <strong>Program</strong> is governed by the terms and conditions of the official agreements<br />
that participants complete with Fidelity Investments and/or MetLife Resources and the HFHS<br />
<strong>403</strong>(b) enrollment form. If this document is in conflict with the official agreements, then the official<br />
agreements remain the final authority.<br />
12. In addition, similar to all HFHS benefit plans/programs, HFHS maintains the right to amend,<br />
modify or terminate the HFHS <strong>403</strong>(b) program at anytime.<br />
Page 8 of 8<br />
2013Dec6
<strong>Henry</strong> <strong>Ford</strong> <strong>Health</strong> <strong>System</strong> <strong>403</strong>(b) <strong>Program</strong><br />
Fidelity Investments<br />
Account Application/Enrollment Form<br />
and Beneficiary Designation<br />
1. GENERAL INSTRUCTIONS<br />
Opening a new account: Please complete this form and sign it on the back. Once your account is established, you can submit a<br />
Contribution Form to your employer, who can then forward contributions to your account. Please contact Fidelity, your employer, or your<br />
tax advisor to determine your maximum allowable contribution.<br />
Moving assets from an existing plan: To consolidate/move money to your employer-sponsored retirement savings account, please<br />
complete the enclosed Transfer/Rollover/Exchange form. If a form was not included within your enrollment kit, please call to request<br />
a form.<br />
Fees: Your account may be subject to an annual maintenance and/or recordkeeping fee.<br />
Mailing instructions:<br />
Return this form in the enclosed postage-paid envelope or to<br />
Fidelity Investments, P.O. Box 770002, Cincinnati, OH 45277-0090<br />
If you wish to send your form via overnight service, please send it to<br />
Fidelity Investments, Mailzone KC1E, 100 Crosby Parkway, Covington, KY 41015<br />
Questions? Call Fidelity Investments at 1-800-343-0860, Monday through Friday, from 8:00 a.m. to midnight Eastern time,<br />
excluding holidays that the New York Stock Exchange is closed, or visit us at www.fidelity.com/atwork.<br />
2. SELECTING YOUR INVESTMENT OPTIONS<br />
In whole percentages, please indicate how you wish to have your contributions allocated to the investment options available for<br />
investment under your plan. Please ensure that your allocations total 100% (for example, 50% for your first, 30% for your second, and<br />
20% for your third fund choice). If your percentages do not add up to 100% or you select an unavailable investment option, your contribution<br />
will be invested in an investment option according to your plan rules.<br />
If you would like to select more than four investment options, please write the fund code, fund name, and allocation percentage<br />
for each additional fund on a separate sheet of paper and attach it to your account application. The fund code can be found in your<br />
investment options brochure. Please note that if you would like to select a different investment mix for your Roth contributions, you<br />
must go to NetBenefits. ®<br />
3. DESIGNATING YOUR BENEFICIARY(IES)<br />
You are not limited to two primary and two contingent beneficiaries. The beneficiaries designated on this form will apply<br />
to all the plans named in Section 1. To assign additional beneficiaries, or to designate a more complex beneficiary designation, please<br />
attach, sign, and date a separate piece of paper. You may revoke the beneficiary designation and designate a different beneficiary by<br />
submitting a new Beneficiary Designation Form to Fidelity or your Human Resources department.<br />
When designating primary and contingent beneficiaries, please use whole percentages and be sure that the percentages<br />
for each group of beneficiaries total 100%. Your primary beneficiary cannot be your contingent beneficiary. If you designate a trust as a<br />
beneficiary, please include the date the trust was created, and the trustee’s name.<br />
If more than one person is named and no percentages are indicated, payment will be made in equal shares to your primary beneficiaries<br />
who survive you. If a percentage is indicated and a primary beneficiary does not survive you, the percentage of that beneficiary’s<br />
designated share shall be divided among the surviving primary beneficiaries in proportion to the percentage selected for them.<br />
4. SPOUSAL CONSENT<br />
Spousal Consent: If you are married, your plan requires you to designate that your spouse receives 50% or more of your vested<br />
account balance in the form of a preretirement survivor annuity. If you are married and you do not designate your spouse as your<br />
primary beneficiary for a portion of your account balances as described above, your spouse must sign the Spousal Consent portion<br />
of this form in the presence of a notary public or a representative of the plan.<br />
Please provide your signature.<br />
5. AUTHORIZATION AND SIGNATURE<br />
Fidelity Investments Institutional Operations Company, Inc.<br />
Page 1<br />
024740001
<strong>Henry</strong> <strong>Ford</strong> <strong>Health</strong> <strong>System</strong> <strong>403</strong>(b) <strong>Program</strong><br />
Fidelity Investments<br />
Account Application/Enrollment Form<br />
and Beneficiary Designation<br />
1. YOUR INFORMATION<br />
Please use a black pen and print clearly in CAPITAL LETTERS.<br />
Social Security<br />
Number:<br />
OR<br />
U.S. Tax ID<br />
Number:<br />
Date of Birth:<br />
Date of Hire:<br />
First Name:<br />
Last Name:<br />
Mailing Address:<br />
Address Line 2:<br />
City:<br />
State:<br />
ZIP:<br />
Daytime Phone:<br />
Evening Phone:<br />
Email Address:<br />
Name of Employer:<br />
Plan Numbers<br />
(if known):<br />
5 3 0 1 4<br />
Employer City/State:<br />
Employer ZIP (if known):<br />
I am: Single OR Married Name of Site/Division:<br />
2. SELECTING YOUR INVESTMENT OPTIONS<br />
Please check here if you are selecting more than four investment options.<br />
Investment Options<br />
Please use whole percentages<br />
Fund Code: Fund Name: Percentage:<br />
%<br />
%<br />
%<br />
%<br />
Total = 100%<br />
Page 2
3. DESIGNATING YOUR BENEFICIARY(IES)<br />
Please check here if you have more than two primary or two contingent beneficiaries.<br />
The beneficiaries designated below shall apply to all the plan numbers named in Section 1. If you do not list plan<br />
numbers, this designation will apply to all retirement plans of the employer named in Section 1 when Fidelity recordkeeps<br />
beneficiary designations.<br />
Primary Beneficiary(ies)<br />
I hereby designate the person(s) named below as primary beneficiary(ies), to receive payment of the value of my account(s) under<br />
the plan upon my death.<br />
1. Individual: OR Trust Name:<br />
Social Security Number: OR U.S. Tax ID Number: Percentage:<br />
%<br />
Date of Birth or Trust Date:<br />
Relationship to Applicant:<br />
Spouse OR Trust OR Other<br />
2. Individual: OR Trust Name:<br />
Social Security Number: OR U.S. Tax ID Number: Percentage:<br />
%<br />
Date of Birth or Trust Date:<br />
Relationship to Applicant:<br />
Spouse OR Trust OR Other Total = 100%<br />
Contingent Beneficiary(ies)<br />
If there is no primary beneficiary living at the time of my death, I hereby specify that the value of my account is to be distributed<br />
to my contingent beneficiary(ies) listed below. Please note: Your primary beneficiary cannot be your contingent beneficiary.<br />
1. Individual: OR Trust Name:<br />
Social Security Number: OR U.S. Tax ID Number: Percentage:<br />
%<br />
Date of Birth or Trust Date:<br />
Relationship to Applicant:<br />
Spouse OR Trust OR Other<br />
2. Individual: OR Trust Name:<br />
Social Security Number: OR U.S. Tax ID Number: Percentage:<br />
%<br />
Date of Birth or Trust Date:<br />
Relationship to Applicant:<br />
Spouse OR Trust OR Other Total = 100%<br />
Payment to contingent beneficiary(ies) will be made according to the rules of succession described under Primary Beneficiary(ies).<br />
4. SPOUSAL CONSENT<br />
I am the spouse of the participant named in Section 1.<br />
By signing below, I hereby acknowledge that I understand (1) that the effect of my consent may result in the forfeiture of benefits I would<br />
otherwise be entitled to receive upon my spouse’s death; (2) that my spouse’s waiver is not valid unless I consent to it; (3) that my consent is<br />
voluntary; (4) that my consent is irrevocable, unless my spouse completes a new Beneficiary Designation; and (5) that my consent (signature)<br />
must be witnessed by a notary public or, if allowed by the plan, a plan representative.<br />
Page 3<br />
024740003
4. SPOUSAL CONSENT (CONTINUED)<br />
I understand that if this beneficiary designation is executed prior to the first day of the plan year in which the participant<br />
turns 35, the waiver of my spousal death benefit as determined by the retirement plan provisions will be restored to<br />
me on the earlier of (a) the first day of the plan year in which the participant attains age 35 or (b) the date the participant<br />
separates from service with the employer sponsoring the retirement plan. After that date, in order for another person to receive the death<br />
benefit that would be restored to me, I would need to consent to a new beneficiary designation.<br />
Signature of Participant’s Spouse:<br />
X<br />
To be completed by a notary public or representative of the plan (if provided for under the terms of your employer’s plan):<br />
Date:<br />
Sworn before me this day<br />
In the state of , County of<br />
Notary Public Signature:<br />
X<br />
My Commission Expires:<br />
Notary stamp must be in the above box<br />
As plan representative, I witnessed the spouse signing this form:<br />
Date:<br />
X<br />
5. AUTHORIZATION AND SIGNATURE<br />
Individual Authorization:<br />
By executing this form<br />
• I certify under penalties of perjury that my Social Security or U.S. taxpayer identification number in Section 1 on this form is correct.<br />
• I acknowledge that I have read the prospectus of any mutual fund in which I invest and that it is my responsibility to read the<br />
prospectus of any fund into which I exchange and agree to the terms.<br />
• If my account is established under a Fidelity Investments Section <strong>403</strong>(b) Individual Custodial Account Agreement, I hereby adopt<br />
the Fidelity Investments Section <strong>403</strong>(b)(7) Custodial Account (the “<strong>Program</strong>”) and certify that I have received and read the Custodial<br />
Agreement. I acknowledge that the provisions of the <strong>Program</strong> shall be governed by the laws of the Commonwealth of Massachusetts.<br />
If my account is established under a Section <strong>403</strong>(b) Group Custodial Agreement, I understand that my employer and Fidelity<br />
Management Trust Company (FMTC) have executed a Fidelity Investments Section <strong>403</strong>(b)(7) Custodial Account Agreement (the<br />
“<strong>Program</strong>”) and that an account under the <strong>Program</strong> has been established on my behalf. I recognize that although FMTC is a bank,<br />
neither Fidelity Distributors Corporation nor any mutual fund in which my accounts may be invested is a bank, and mutual fund<br />
shares are not backed or guaranteed by any bank or insured by the FDIC.<br />
• I understand that I may designate a beneficiary for my assets accumulated under the plan, and that if I choose not to designate a<br />
beneficiary, my beneficiary will be my surviving spouse, or if I do not have a surviving spouse, distributions will be made based on<br />
the provisions of the plan.<br />
• I understand that my account may be subject to an annual maintenance and/or recordkeeping fee.<br />
Your Signature: X Date:<br />
Check this box if you are signing this form as an attorney-in-fact under a power of attorney.<br />
624244.1.0 Fidelity Investments Institutional Operations Company, Inc. 3.EPCP53014002.101<br />
Page 4