Irrevocable Retirement Plan Election

Please check all boxes to acknowledge:

I certify that I have been enrolled in a Utah Retirement Systems (“URS”) retirement plan with another employer.

I acknowledge that under 2010 General Session Utah Senate Bill 171 (“SB 171”) I have an irrevocable option, to request participation in Utah Public Employees' Noncontributory Retirement System despite my employing institution's employment classification assignment. I acknowledge this is a one-time irrevocable election and is contingent upon Utah Retirement Systems (“URS”) approval.

I hereby make this election and authorize the University to change my retirement plan from the University of Utah Defined Contribution Retirement Plan (the “401(a) Plan”) to the Utah Retirement Systems Noncontributory Plan (“URS Noncontributory Plan”) retroactive to my date of hire.

I acknowledge that as a result of this election, the University will not make contributions to the 401(a) Plan on my behalf. I understand my signed election must be received by the University’s Benefits Department within one pay period of my date of hire with the University or I will be ineligible to make this election.

Name

First

Last

Date

UNID/Employee ID

Signature

If you are human, leave this field blank.