Election

401(k) Pension Plan: Payroll Deduction Authorization Form*

1. Pre-Tax to or to my

____________% of base compensation OR $_________________ per pay period

2. Voluntary After-Tax Electionto or to my

____________% of base compensation OR $_________________ per pay period

3. Roth 401(k) Electionto or as to my

____________% of base compensation OR $_________________$ per pay period

4. Decline Participation

EFFECTIVE DATE (MONTH, YEAR)

HIRE DATE (OR PRIOR COOPERATIVE SERVICE DATE IF ANY)

EMPLOYEE NAME (PRINT)

SIGNATURE OF HUMAN RESOURCE REPRESENTATIVE

EMPLOYEE SIGNATURE

*Please check with your benefits administrator about the contribution types offered by your co-op.

Employee Authorization

I understand that my 401(k) Pension Plan contributions will be invested in Target Date Portfolio(s) until I make my own investment allocations. These allocations can be made by logging into Cooperative.com > My Benefits > My Retirement > Investment Allocations or by calling 866.673.2299, option 6.

I have been given the opportunity to contribute to the 401(k) Plan and elect to decline at this time. I understand I may contribute at any time in the future, subject to my employer's payroll practices, by completing the appropriate payroll form.

IMPORTANT: If you have made pre-tax contributions to another employer’s 401(k) plan during the current tax year, the 401(k) Plan annual pre-tax maximum must be reduced

by the amount previously contributed to that other plan.

3. 201 120 2017

4.

Annual Maximum Contribution Table

Year Maximum Catch-up Amount(Employees age 50 and older only)

201 8 000 6 000

IMPORTANT: Please review your paycheck carefully to make sure your payroll deductions are correct. Contact your benefits administrator regarding any discrepancies as soon as possible.

Contribution Notes

The 2017 maximum contribution that may be made to your 401(k) Plan account (including all employee and employer contributions) is 100% of your compensation up to $54,000.

The maximum pre-tax contribution that you may elect to defer is indicated on the annual maximum contribution table below.

1.

2.

If you are eligible to make the catch-up contribution, the 401(k) Plan will not return any pre-tax deferrals (posted to your account) that are in excess of your election, but are less than the maximum limit, including the catch-up amount (i.e., $24,000 for 2017).