Retirement Contribution Exemption Form
Request an exemption from retirement contribution deductions. Please complete all required fields to submit your exemption request.
Full Name
*
First Name
Last Name
Employee ID
*
Department or Division
Employer or Plan Name
*
Exemption Reason
*
Please Select
Eligibility criteria met
Temporary employment status
Part-time or contract role
Already contributing to another plan
Other
Effective Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Effective End Date (if applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please provide a brief explanation supporting your exemption request
*
Upload any supporting documents (optional)
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I confirm that the information provided above is accurate and understand that providing false information may result in disciplinary action.
*
I acknowledge and agree
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