’

-

___________________________________________ ______________________________________________

___________________________________________ ______________________________________________

*Form In Lieu of Social Security must be

S A L A R Y D E F E R R A L A G R E E M E N T I R C S E C T I O N 4 5 7 return to L o u i s i a n a P u b l i c E m p l o y e e s D e f e r r e d C o m p e n s a t i o n P l a n HRM

MAIL: State of LA, P O Box 173764, Denver, CO 80217-3764 TELEPHONE: 800-937-7604 FAX: 866-745-5766

EMPLOYER /AGENCY NAME EMPLOYER ADDRESS/LOCATION PLAN #/ DEPT#

LSU-BR 110 Thomas Boyd Hall Baton Rouge, LA 70803 Office telephone (225) 578-8200

98228-01 /

EMPLOYEE NAME & ADDRESS: SOCIAL SECURITY #:

______________________________ __________________________ ____ Last Name First Name MI

_____________________________________________________________________ Address – Street & Number

__________________________________ / ___________ / ___________________ City State Zip Code

*EMAIL ADDRESS: ________________________________________

__ __ __ - __ __ - __ __ __ __

ANNUAL SALARY: $

Home # ( _ _ _ ) _ _ _ - _ _ _ _

Cell # ( _ _ _ ) _ _ _ - _ _ _ _

PAY PERIODS: WEEKLY BI-WEEKLY SEMI-MONTHLY MONTHLY

SELECT ONE OF THE FOLLOWING:

New Enrollment Increase Contributions One Time Annual Leave/Lump-Sum Pay

Single Payroll Deferral Restart Contributions – Rehire Date: ______________(if applicable)

Decrease Contributions Stop Contributions Change of Deferral Type only (before-tax/after-tax)

X

CONTRIBUTION ELECTION: 2020 ANNUAL LIMIT: $19,500 or 2020 AGE 50+ LIMIT: $26,000 PARTICIPANTS ARE RESPONSIBLE FOR MONITORING THEIR CONTRIBUTIONS AND LIMITS

“BEFORE-TAX CONTRIBUTIONS” Amount $__________OR__________% per pay period I hereby authorize and direct my Employer to deduct from my GROSS salary.

ROTH “AFTER-TAX CONTRIBUTIONS” Amount $ __________OR__________% per pay period

I hereby authorize and direct my Employer to deduct from my NET salary.

NOTE: If selecting both Before-Tax AND Roth After-Tax contributions per paycheck, you must select an amount or a percentage. A percentage cannot be selected for one and an amount for the other.

LEAVE PAY/LUMP-SUM PAY: I wish to direct all of my first 300 hours of leave pay (if available) from my last paycheck not to exceed the annual contribution limit.* Final paycheck date: _________________ (Form must be received the month prior to

your final paycheck date.) OR

LEAVE PAY/LUMP-SUM PAY: I wish to direct $_________________ of leave pay from my last paycheck not to exceed the annual contribution limit. Final paycheck date: __________________ (Form must be received the month prior to your final paycheck date.)

*Please include your email address so that we may confirm your final calculation.

7.5 X

PAYCHECK EFFECTIVE DATE: *OSUP paid employees contributions will take effect 2 full paychecks after the completed paperwork is received in good order; all others take effect the MONTH after completed paperwork is received in good order.

To elect a future paycheck date other than the default: _______________, ______________, 20__________ Mo Day Year

SPECIAL CATCH UP FORMS: Contact the Baton Rouge office.

REQUIRED SIGNATURES: I have reviewed, understand, and agree to the provisions as stated on the reverse side of this form. understand and agree to monitor my contributions and annual limits to avoid over deferring.

Participant Signature Date

Authorized Commission Signature Date

For agencies with matching contributions. (There is no match for State Agencies)

EE Contribution $___________________ + Employer Contribution $____________________= Total $_______________________ 7.5% 6.2% 13.7%

IRC 457 Salary Deferral Agreement G738A (rev. March 2020)

I

Salary Deferral Agreement

IRC Section 457 Plan Provisions

Whereas the Louisiana Deferred Compensation Commission, hereinafter referred to as the “Commission” has established the Louisiana Public Employees Deferred Compensation Plan, hereinafter referred to as “the Plan” pursuant to Internal Revenue Code (the “Code”) Section 457; and Louisiana R.S. 42:1301-1308; and

Whereas I, as the employee, have elected to participate in the Plan by deferring a portion of my salary into the Plan, it

is hereby agreed as follows:

I authorize and request my Employer to reduce my salary as of the effective date designated on the front of this form (this date cannot precede the date on which this agreement is signed), and direct my Employer, its proper officers, agents and employees forward these deferrals to the Plan. The deferral agreement will be effective in the following calendar month, and is subject to the ability of my Employer to process this request. In the alternative, this deferral agreement will go into effect at the next available pay period.

I agree and understand that increasing, decreasing or stopping the amount deferred per pay period requires that a new Agreement be submitted to be effective in the following calendar month, and is subject to the ability of my Employer and the Plan to process this request. If I experience an unforeseeable emergency distribution, deferrals will be suspended for a minimum time period of six months as designated by the Plan.

Effective, January 1, 2015, participants may begin directing their deferrals to ROTH after-tax contributions. I understand that Code Section 457 limits the amount that I may defer each year, to the lesser of 100% of compensation, up to the annual deferral amount ($19,500 in 2020). Additionally, if age 50 or older, I may elect the Age 50+ provision to defer an additional amount ($6,500 in 2020) above the annual deferral limit, for a total annual deferral of $26,000 in 2020. The IRS annual contribution limit takes into account a combination of both pre and after tax dollars. I may increase my deferrals in future years as the IRS and Plan Document provides.

During the three calendar years ending prior to my normal retirement age as defined by the Plan, I may be eligible to

contribute a 457 “Special Catch-Up” amount if I did not contribute the maximum allowable amount during the years of my eligibility in the Plan since January 1, 1979. I understand that this provision may not be used during the calendar year if the Age 50+ provision is elected, nor may a catch-up contribution be made during the calendar year of my normal retirement age, nor may a catch-up contribution be made if I previously participated in Special Catch-Up under this or any other Section 457 Plan. It is my responsibility to monitor the amount I contribute per pay period to ensure that my total annual contributions to the Plan do not exceed the amount permitted under the Internal Revenue

Code, as amended from time to time. I agree to execute a new Agreement to avoid contributing excess amounts.

I understand that this Agreement is irrevocable as to salary earned while the Agreement is in effect. However, I may terminate the Agreement at any time with respect to amounts not yet earned by submitting written notice to the Employer. I understand that the Employer will reduce my salary pursuant to the terms of this Agreement only to the extent that the amount of my gross salary for any pay period exceeds the amount I have elected to defer in any pay

period.

I understand that in general, distributions may not be made from this Section 457 Plan until the earlier of my retirement, severance from employment with the Employer, in-service distribution at age 70½ or older, in-service DeMinimis, Purchase of Defined Benefit Plan Service Credit, death or upon my experiencing an unforeseeable emergency as defined by the Plan. If an employee incurs a break in service for a period of less than 30 days or transfers among various Louisiana governmental entities, such

break or transfer shall not be considered a severance from employment.

In consideration of the Employer’s compliance with the terms of this Agreement, I agree to hold the Commission, my Employer, Empower Retirement®, it’s members, officers, agents, employees, successors and assigns harmless from and against any and all liability whatsoever arising out of or in connection with this Agreement, including but not limited to any costs or tax penalties that I may incur as a result of, or in connection with, the authorization and direction given by me in this Agreement.

For more information, please call:

LOCAL (225) 926-8082 TOLL-FREE (800) 937-7604

IRC 457 Salary Deferral Agreement G738A (rev. March 2020)

05/24/19 MANUAL/LDOM/SR 6553845 Page 1 of 1

I understand that funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in thefund’s prospectus or other disclosure documents. I understand that I have the right to direct the investment of my account and that I can change myinvestment allocation from the Plan’s default fund at any time by logging on to my account at www.louisianadcp.com or by calling KeyTalk® at1-800-701-8255. A personal identification number (PIN) that gives you access to your account via the Web or phone will be mailed to you soon afteryour application is processed. You are responsible for keeping the assigned PIN confidential. Please contact us if you suspect unauthorized use.

Quick Enrollment Governmental 457(b) Plan

Louisiana Public Employees Deferred Comp. Plan 98228-01

Participant Information Yes! I would like to enroll in the Louisiana Public Employees Deferred Comp. Plan and voluntarily contribute:

$________ or ________% per pay period of my eligible compensation on a Before Tax basis. 7.5 $________ or ________% per pay period of my eligible compensation on a Roth basis. I do not wish to contribute to the Plan at this time.

X

Last Name First Name MI (The name provided MUST match the name on le with Service Provider.)

Address - Number & Street

City State Zip Code

( ) Home Phone

(

LSU-BR Employer / Agency Name

) Work Phone

Social Security Number

❑ Married

E-Mail Address

❑ Unmarried ❑ Female ❑ Male

Mo Day Year Mo Day Year

Date of Birth Date of Hire Do you have a retirement savings account with a previous employer or an IRA? ❑ Yes ❑ No

Investment Option: I understand that this form is my election to enroll in the Plan. By signing this form, my contributions will be allocated to the Plan’s default investment fund without additional action by me. If I wish to contribute to any of the investment options of the Plan other than the default fund, I understand that I must contact my Plan Administrator or local representative to obtain a Participant Enrollment Form. The Plan has selected a TARGET DATE portfolio of funds as its default investment fund. Until such time as you choose investment options for your Plan account, your contributions will be invested in the fund within this portfolio that most closely corresponds to certain factors in your profile. For more information, please contact your GWRS Representative. I acknowledge that information about Plan investment options, including prospectuses, disclosure document and Fund Data sheets are available to me through my Plan Administrator or Plan Web site. I understand the risks of investing and that all payments and account values may not be guaranteed and may fluctuate in value.

I understand that funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund’s prospectus or other disclosure documents. I understand that I have the right to direct the investment of my account and that I can change my investment allocation from the Plan’s default fund at any time by logging on to my account at www.louisianadcp.com or by calling the Voice Response System at 1-800-937-7604. A personal identi cation number (PIN) that gives you access to your account via the Web or phone will be mailed to you soon after your application is processed. You are responsible for keeping the assigned PIN con dential. Please contact us if you suspect unauthorized use. My Account: I understand that it is my obligation to review all confirmations and quarterly statements for discrepancies or errors. Corrections will be made only for errors which I communicate within 90 calendar days from the last calendar quarter. After this 90 days, account information shall be deemed accurate and acceptable to me. If I notify Service Provider of an error after this 90 days, the correction will only be processed from the date of the notification forward and not on a retroactive basis.

Beneficiary Designation: I understand that I must choose a beneficiary of my account with this Plan by filing a separate Beneficiary Designation form with the Service Provider.

Required Signature - By signing this form, I verify that this enrollment was unsolicited. I also acknowledge that I have previously received detailed information about this Plan from my employer and understand that my participation in the Plan must be in compliance with the Plan Document and/or the Internal Revenue Code. I understand that Service Provider is required to comply with the regulations and requirements of the Office of Foreign Assets Control, Department of the Treasury ("OFAC"). As a result, Service Provider cannot conduct business with persons in a blocked country or any person designated by OFAC as a specially designated national or blocked person. For more information, please access the OFAC Web site at: http://www.treasury.gov/about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx. Deferral agreements must be entered into prior to the first day of the month that the deferral will be made.

X Participant Signature Date A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a signi cant delay.

Email to: hr@lsu.edu Securities offered through GWFS Equities, Inc., Member FINRA/SIPC, and/or other broker-dealers. Retirement products and services provided by Great-West Life & Annuity Insurance Company, Corporate Headquarters: Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York, Home Office: New York, NY, and their subsidiaries and affiliates, including GWFS and registered investment advisers Advised Assets Group, LLC and Great-West Capital Management, LLC.

ALL FQUICK 10/09/19 98228-01 ADD NUPART MANUAL/DAES/SR 7143230 Page 1 of 1

mailto:hr@lsu.eduhttp://www.treasury.gov/about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspxhttp:www.louisianadcp.com

][ )(][ )( ][

)(

Beneficiary DesignationGovernmental 457(b) Plan

Louisiana Public Employees Deferred Comp. Plan 98228-01 For My Information • For questions regarding this form, visit the website at www.louisianadcp.com or contact Service Provider at 1-800-937-7604. • Use black or blue ink when completing this form.

A Participant Information Account extension, if applicable, identifies fundstransferred to a beneficiary due to participant'sdeath, alternate payee due to divorce or a participant with multiple accounts.

- -

Account Extension Social Security Number (Must provide all 9 digits)

Last Name First Name M.I. (The name provided MUST match the name on file with Service Provider.)

Email Address

Married Unmarried

/ / Date of Birth ( ) Daytime Phone Number ( ) Alternate Phone Number

B Beneficiary Designation (Attach an additional sheet to name additional beneficiaries.) Primary Beneficiary Designation (Primary beneficiary designations must total 100% - percentage can be made out to two decimal places.)

● See the attached examples on how to complete the below beneficiary designations if the beneficiary is a non-individual, such as a trust, charity or estate.

% / / % of Account Balance Primary Beneficiary Name

(Name of Individual, Trust, Charity, etc.) Social Security or Taxpayer Identification Number

Date of Birth or Trust Date

Street Address City State Zip Code ( ) Relationship (Required - If Relationship is not provided, request will be rejected and sent back for clarification.) Phone Number (Optional) Spouse Child Parent Grandchild Sibling My Estate A Trust Other

Domestic Partner % / /

% of Account Balance Primary Beneficiary Name (Name of Individual, Trust, Charity, etc.)

Social Security or Taxpayer Identification Number

Date of Birth or Trust Date

Street Address City State Zip Code ( ) Relationship (Required - If Relationship is not provided, request will be rejected and sent back for clarification.) Phone Number (Optional) Spouse Child Parent Grandchild Sibling My Estate A Trust Other

Domestic Partner % / /

% of Account Balance Primary Beneficiary Name (Name of Individual, Trust, Charity, etc.)

Social Security or Taxpayer Identification Number

Date of Birth or Trust Date

Street Address City State Zip Code ( ) Relationship (Required - If Relationship is not provided, request will be rejected and sent back for clarification.) Phone Number (Optional) Spouse Child Parent Grandchild Sibling My Estate A Trust Other

Domestic Partner

Contingent Beneficiary Designation (Contingent beneficiary designations must total 100% - percentage can be made out to two decimal places.)

% / / % of Account Balance Contingent Beneficiary Name

(Name of Individual, Trust, Charity, etc.) Social Security or Taxpayer Identification Number

Date of Birth or Trust Date

Street Address City State Zip Code ( ) Relationship (Required - If Relationship is not provided, request will be rejected and sent back for clarification.) Phone Number (Optional) Spouse Child Parent Grandchild Sibling My Estate A Trust Other

Domestic Partner

NO_GRPG 53706/ GU22 / GP22 STD FBENED 06/16/20 98228-01 CHG NUPART DOC ID: 650534698

Page 1 of 4

][ )(][ )( ][

)(

98228-01 Last Name First Name M.I. Social Security Number Number

B Beneficiary Designation (Attach an additional sheet to name additional beneficiaries.) Contingent Beneficiary Designation (Contingent beneficiary designations must total 100% - percentage can be made out to two decimal places.)

% / / % of Account Balance Contingent Beneficiary Name

(Name of Individual, Trust, Charity, etc.) Social Security or Taxpayer Identification Number

Date of Birth or Trust Date

Street Address City State Zip Code ( ) Relationship (Required - If Relationship is not provided, request will be rejected and sent back for clarification.) Phone Number (Optional) Spouse Child Parent Grandchild Sibling My Estate A Trust Other

Domestic Partner % / /

% of Account Balance Contingent Beneficiary Name (Name of Individual, Trust, Charity, etc.)

Social Security or Taxpayer Identification Number

Date of Birth or Trust Date

Street Address City State Zip Code ( ) Relationship (Required - If Relationship is not provided, request will be rejected and sent back for clarification.) Phone Number (Optional) Spouse Child Parent Grandchild Sibling My Estate A Trust Other

Domestic Partner

C Participant Consent for Beneficiary Designation (Please sign on the 'Participant Signature' line below.) I have completed, understand and agree to all pages of this Beneficiary Designation form. Subject to and in accordance with the terms of the Plan, I am making the above beneficiary designations for my vested account in the event of my death. If I have more than one primary beneficiary, the account will be divided as specified. If a primary beneficiary predeceases me, his or her benefit will be allocated to the surviving primary beneficiaries. Contingent beneficiaries will receive a benefit only if there is no surviving primary beneficiary, as specified. If a contingent beneficiary predeceases me, his or her benefit will be allocated to the surviving contingent beneficiaries. If I fail to designate beneficiaries, amounts will be paid pursuant to the terms of the Plan or applicable law. This designation is effective upon execution and delivery to Service Provider. If any information is missing, additional information may be required prior to recording my designation. This designation supersedes all prior designations. Beneficiaries will share equally if percentages are not provided and any amounts unpaid upon death will be divided equally. Primary and contingent beneficiaries must separately total 100%. The percentages can be divided up to twodecimal points (Example: 33.33%). I understand that Service Provider is required to comply with the regulations and requirements of the Office of Foreign Assets Control, Department of the Treasury ("OFAC"). As a result, Service Provider cannot conduct business with persons in a blocked country or any person designated by OFAC as a specially designated national or blocked person. For more information, please access the OFAC website at: http://www.treasury.gov/ about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx.

Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.

Participant Signature Date (Required) A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.

D Delivery Instructions

Email to: hr@lsu.edu

or Return to: 110 Thomas Boyd Hall

Securities offered by GWFS Equities, Inc., Member FINRA/SIPC, marketed under the Empower brand, and/or other broker-dealers. GWFS is affiliated with Great-West Funds, Inc.; Great-West Trust Company, LLC; and registered investment advisers Advised Assets Group, LLC and Great-West Capital Management, LLC, marketed under the Great-West Investments™ brand.

NO_GRPG 53706/ GU22 / GP22 STD FBENED 06/16/20 98228-01 CHG NUPART DOC ID: 650534698

Page 2 of 4

98228 SDA 2020 MARCH 202098228-01_FQUICK_20191010101804isisDocument-2159639-FORMS-650534698-737799398-FBENED

Last Name: First Name: MI: Address Street Number: ANNUAL SALARY: City: State: Zip Code: EMAIL ADDRESS: WEEKLY: OffBIWEEKLY: OffSEMIMONTHLY: OffMONTHLY: OffSocial Security Number: EMail Address: Unmarried: OffFemale: OffMale: OffDo you have a retirement savings account with a previous employer or: OffAccount Extension: Social Security Number Must provide all 9 digits: undefined_2: undefined_3: MI_2: Email Address: Street Address: City_2: State_2: Zip Code_2: Street Address_2: City_3: State_3: Zip Code_3: Street Address_3: City_4: State_4: Zip Code_4: Street Address_4: City_5: State_5: Zip Code_5: Last Name_3: First Name_3: MI_3: Social Security Number_2: Street Address_5: City_6: State_6: Zip Code_6: Street Address_6: City_7: State_7: Zip Code_7: SSN1: SSN2: SSN3: SSN4: SSN5: SSN6: SSN7: SSN8: SSN9: Cell number area code: Home number area code: Home number first three numbers: Home number last four numbers: Cell number first three numbers: Cell number last four numbers: First Name 1: Middle Initial 1: Address 2: City 2: State 2: Zip Code 2: Last Name 1: Cell phone number 2: Home phone number 2: Date of birth day: Date of birth year: Date of birth Month: Date of hire Month: Date of hire day: Date of hire year: First Name_2: Date of birth month 1: Date of birth day 1: Date of birth year 1: Last Name_2: Alternate Phone Number: Married: OffDaytime Phone Number: Primary Beneficiary Phone Number 2: Primary Beneficiary Phone Number 3: Primary Beneficiary Phone Number: Contingent Beneficiary Phone Number 2: Contingent Beneficiary Phone Number: Contingent Beneficiary Phone Number 3: % of Account Balance 2: % of Account Balance 3: % of Account Balance 4: % of Account Balance 5: % of Account Balance: % of Account Balance 6: Date of birth month 4: Date of birth month 5: Date of birth month 6: Date of birth month 7: Date of birth month 3: Date of birth month 8: Date of birth day 4: Date of birth day 5: Date of birth day 6: Date of birth day 3: Date of birth day 7: Date of birth day 8: Date of birth year 4: Date of birth year 5: Date of birth year 6: Date of birth year 3: Date of birth year 7: Date of birth year 8: Primary Beneficiary Name 2: Primary Beneficiary Name 3: Contingent Beneficiary Name: Contingent Beneficiary Name 2: Primary Beneficiary Name: Contingent Beneficiary Name 3: Primary Beneficiary SSN or Taxpayer ID 2: Primary Beneficiary SSN or Taxpayer ID 3: Contingent Beneficiary SSN or Taxpayer ID: Contingent Beneficiary SSN or Taxpayer ID 2: Primary Beneficiary SSN or Taxpayer ID: Contingent Beneficiary SSN or Taxpayer ID 3: Check Box5: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box6: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box23: OffCheck Box24: OffCheck Box25: OffCheck Box26: OffCheck Box27: OffCheck Box28: OffCheck Box29: OffCheck Box30: OffCheck Box31: OffCheck Box32: OffCheck Box33: OffCheck Box34: OffCheck Box35: OffCheck Box36: OffCheck Box37: OffCheck Box38: OffCheck Box39: OffCheck Box40: OffCheck Box41: OffCheck Box42: OffCheck Box43: OffCheck Box44: OffCheck Box45: OffCheck Box46: OffCheck Box47: OffCheck Box48: OffCheck Box49: OffCheck Box50: OffCheck Box51: OffCheck Box52: OffCheck Box53: OffCheck Box54: OffCheck Box55: OffCheck Box56: OffCheck Box57: OffCheck Box58: OffCheck Box59: OffCheck Box60: OffCheck Box61: Off