Retirement Enrollment

Complete the form below to get started.

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Retirement Plan Enrollment

Personal Information

Please complete this form in its entirety.

U.S. Citizen(Required)

Ordained minister or missionary? (If not, select N/A):(Required)

Gender(Required)

Marital Status(Required)

Full Name(Required)

First Middle Last

Date of Birth(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone(Required)

Work Phone

Social Security Number(Required)

Email Address

Employer

Employer Name(Required)

Job Title(Required)

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Church Treasurer / Payroll Administrator Name

Church Treasurer / Payroll Administrator Email

Beneficiaries

Primary Beneficiary

I designate the following as my primary beneficiary(ies): (Must be spouse if legally married unless waiver is filed)

Full Name(Required)

First Middle Last

Date of Birth(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code

Social Security Number(Required)

Relationship to you(Required)

Share Percentage %(Required)

Full Name

First Middle Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Social Security Number

Relationship to you

Share Percentage %(Required)

Contingent Beneficiary(ies)

I designate the following as my contingent beneficiary(ies): (In the event the primary beneficiary is deceased, the contingent beneficiary(ies) will receive the funds in the account)

Full Name

First Middle Last

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code

Social Security Number

Relationship to you

Share Percentage %

Full Name

First Middle Last

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Social Security Number

Relationship to you

Share Percentage %

Full Name

First Middle Last

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code

Social Security Number

Relationship to you

Share Percentage %

Full Name

First Middle Last

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code

Social Security Number

Relationship to you

Share Percentage %

Term Life Insurance

Group term life insurance is available through Guardian Insurance Company for enrollees who are under 65 years of age. The Basic Term Life Coverage is $25,000 (for as long as you have a retirement plan with Richland Ave Financial). The monthly premium of $16.50 is deducted from the contributions to your retirement account. You can find more information regarding this Group Term Life Insurance policy here.

Term Life Insurance

Yes, I want Group Term Life Insurance coverage; complete "Retirement Plan Life Insurance" application after submitting this enrollment..

No, I do not want Group Term Life Insurance coverage.

Investment Selection

You may invest in one (1) or all investment options. Indicate desired percentage to invest in each option (must total 100%). If no choice is made, all funds remain in the Default Strategy.

Investment Options (See Investment Plan Options for a description)

The Set Rate Fund*

The Moderate Strategy*

The Default Strategy*

The Maximum Strategy*

All Cap Growth Equity

Large Cap Growth

Large Cap Value

SMID Cap

Real Estate (REITs)

Intermediate Fixed Income

Short Term Fixed Income

Total

Total must equal 100%

* Preset Plan with set allocations (For more information about Preset Plans, see Investment Plan Options)

Certification

I request Richland Ave Financial invest my accumulations/contributions based upon my investment choices above. I have reviewed information provided by Richland Ave Financial and make this selection using my own investment judgment. I realize past results are not a guarantee of future performance. If I need additional information, I know I can contact Richland Ave Financial.

Date(Required)

Please enter todays date (mm/dd/yyyy)

Signature(Required)

Use your mouse (or finger if on a mobile device) to sign your name in the box below.

Referral

If you were referred to Richland Ave Financial or heard about us at an event, please let us know in the box below.

Referral

Retirement Enrollment

Complete the form below to get started.

Retirement Plan Enrollment

Personal Information

Employer

Beneficiaries

Primary Beneficiary

Contingent Beneficiary(ies)

Term Life Insurance

Investment Selection

Certification

Referral

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