Money Purchase Plan by qsq57085

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									                              University of Wisconsin Medical Foundation
                                    Money Purchase Pension Plan

                           Irrevocable election of contribution to the pension plan
This form must be returned to the Plan Administrator within 3 days of employment. If not returned, a default
                              provision (25% annual contribution) will apply.

I, ___________________________ , hereby make an irrevocable election, prior to commencing participation in the
University of Wisconsin Medical Foundation, Inc. Money Purchase Pension Plan (the “Plan”), to have a specified
amount allocated to me under the Plan each year which is equal to or less than the maximum amount that would be
contributed on my behalf. I acknowledge that the maximum contribution that could be made on my behalf is 25% of
W-2 compensation. I realize I will never be able to change this decision as long as I am employed by the University of
Wisconsin Medical Foundation, Inc., even if it adopts to other qualified retirement plans, unless federal law is
amended to permit it.

                                           Specified Contribution
I hereby elect to receive annual contributions to the University of Wisconsin Medical Foundation, Inc. Money
Purchase Plan as follows:

            Time period for application of percentage                                        Percentage of W-2 income
           (must use calendar year-end dates, 12/31/--)                                    for the time periods indicated
                                                                                               (may not exceed 25%)

From ____________________ to __________________________                                                         _____ %
         (fill in 1st date on payroll)        (fill in year-end date, 12/31/--, or write “termination*”)       (whole numbers only)


From ____________________ to __________________________                                                         _____ %
                                              (fill in year-end date, 12/31/--, or write “termination*”)       (whole numbers only)


From ____________________ to __________________________                                                         _____ %
                                              (fill in year-end date, 12/31/--, or write “termination*”)       (whole numbers only)


From ____________________ to __________________________                                                         _____ %
                                              (fill in year-end date, 12/31/--, or write “termination*”)       (whole numbers only)



        Signature _______________________________                       Date ______________________

                                                       Receipt
       This election was received on __________________________, 20 _____ .
        Plan Administrator ___________________________________
        (Once you have returned your election form, the Plan Administrator will sign and date it and return a copy to
        you as your acknowledgement. Your election will not be effective until it has been signed by the Plan
        Administrator).
* Termination is defined as the end of your employment with the University of Wisconsin Medical Foundation


                                  Return completed form to :
            UWMF Director of Human Resources; 555 Zor Shrine Place, Madison, WI 53719

								
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