Common use of Select one below Clause in Contracts

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. □ 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. □ 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.