Select one below. □ New Enrollment □ Change Amount □ Add a 2nd Account □ Cancel Account Employee: SSN: Address: City: State: Zip: Phone Number: Date of Birth: I. Employee Deferrals – Section 403(b) or 457(b) Pre-tax Deferral Election. I hereby authorize the Kenosha Unified School District ("District") to withhold $ OR % (whole dollar amount or whole percentage of total pay period compensation) from my compensation per pay period. This Agreement shall be effective as of the first pay date which is not less than ten (10) business days following the date of execution of this Agreement. The District shall remit the withheld funds to the following Vendor(s) that I have selected: Amount (whole dollar/percentage) District-Approved Vendor Name $ OR % Amount (whole dollar/percentage) District-Approved Vendor Name $ OR % Please use the back of this form, continuing in the same fashion above if you wish to select additional vendors.
Select one below. I am transferring a decedent’s existing Pacific Funds IRA account to an Inherited IRA. I have completed the IRA Inheritance Request Form and have included it with this application. I am requesting a trustee-to-trustee transfer of assets from an existing Inherited IRA held at another insitituion. I have completed the enclosed IRA Transfer of Assets/Direct Rollover Form. I am establishing an inherited IRA to accept a non-spouse beneficiary direct rollover from a 403(b) or qualified plan.
Select one below. ¨ For active Participants only. x For active Participants, terminated Participants and Beneficiaries.
Select one below. Yes* No *Names will not be included without specifically contacting parents for permission at that time. We at JCNWJ are proud of our children and seek opportunities to share pictures of accomplishments as well as celebrations and activities throughout the year. We will only post pictures of children with signed parental permission. Please complete the below consent. For those granting permission, please read and sign the following: I hereby irrevocably consent and grant to JCNWJ the perpetual right to distribute, transmit, publish, copy, exhibit or otherwise utilize, either in whole or in part, either in print, digitally or in any other medium now known or later discovered, media incorporating the likeness of my child(ren) without compensation in their publications at their discretion such as, but not limited to, their website, social media, bulletin, promotional materials and/or educational materials. I understand and agree that the media with my child(xxx)’s likeness may be used with or without attribution, and that the media may be modified or edited from its original form. I release and discharge JCNWJ and their agents, representatives and assignees from any claim or cause of action, now known or later discovered, for, among other things, invasion of privacy, right of publicity, and defamation arising out of the use of the media. Student Name(s):
