401k Enrollment/Change Form For Full Time Employees

401k Enrollment/Change Form For Full Time Employees

Pediatric Advanced Therapy 401(k) Profit Sharing Plan and Trust 809558-000
Social Security Number*
Employee Information
Name*

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Date of Hire

MonthDayYear
Date
Marital Status*

MarriedNot Married
Reason for Form*

I am eligible and am enrolling in the PlanI am changing my future investment mixI am changing my current contribution levelsI am changing or stopping my catch-up contributionsI am stopping all of my contributionsI am changing my beneficiary designationI elect not to make contributions to the plan at this time
* If you elect to join the Plan and fail to make an investment choice election, or your elections do not total to 100%, your contribution will be invested by the Plan's default. Please contact your Plan Administrator for specifics regarding your plan's default investment choices.
Contribution Amount
Before Tax Contribution
I wish to contribute $ before tax dollars Or %before tax % of my eligible pay on a before tax-basis (minimum contribution amounts are 3% or $50/paycheck).
After Tax Contribution
I wish to contribute $ after tax dollars Or %after tax % of my eligible pay on a after tax-basis (minimum contribution amounts are 3% or $50/paycheck).
Catch-Up Contributions

You may elect or change your Catch-Up Contribution at any time. The effective date of your election is based on your Plan's provisions. Other factors may also affect your Catch-Up Contributions. Therefore, please read the Important Notes below before making an election.
I elect to contribute $ blanks Or %blankper pay period of my eligible earnings as a Catch-up Contribution.
Important Notes
- If you exceed IRS/Plan limits (limits apply to the sum of before-tax or after-tax 401(k) contributions), the excess will be automatically re-characterized as Catch-up Contributions, up to the limit for Catch-up Contributions for the year.
- With the exception of one-time deductions, your Catch-up Contribution election will carry over from year to year
- The investment mix of Catch-up Contributions will be the same as your regular contributions. The IRS/Plan limits may affect the amount you can contribute to the plan each year.
- If you are making Catch-up Contributions but do not satisfy both the age and contribution requirements, your Catch-up Contributions will be re-characterized as regular contributions at the end of the year.
- Catch-up Contributions will be allocated in the same proportion as your total elective contribution. For example, if you have elected to contribute 6% of your traditional 401(k) account and 4% of your Roth 401(k) account, 60% of your total elective contrubtion will be directed into your traditional 401(k) account and 40% will be directed into your Roth 401(k) account.

Other Options

I elect to stop making Catch-Up ContributionsI do not wish to make Catch-Up Contributions at this timeI will not be at least age 50 by the end of the year
Investment Mix

Please invest my future Plan contributions in the Pediatric Advanced Therapy 401(k) Profit Sharing Plan and Trust as indicated below, in whole percentages.

Enter all elections as a %. Must total 100%

	Election %
Transamerica Stable Value Core (Q1QS)
AB High Income (R3LG)
State Street US Bond Index (R3BU)
Western Asset Core Plus Bond (R3Q8)
Mainstay Mackay High Yield Corporate Bond (R3SG)
MFS Large-Cap Value (R3P7)
TA Vanguard Total Stock Market Index (R3EQ)
MainStay Large Cap Growth (R3RZ)
MFS Mid Cap Value (R3PU)
State Street S&P Mid Cap Index (R3BS)
Hartford Mid-Cap (R3L2)
DFA US Targeted Value Portfolio (R3CG)
State Street Russell Small Cap Index (R3BN)
Janus Henderson Triton Small Cap (R3L7)
TA Vanguard Real Estate Index (R3EN)
American Funds New Perspective International (R3HH)
State Street International Index (R3BQ)
DFA Emerging Markets Portfolio (R3CC)
TA BlackRock Lifepath Index Retirement (R3CL)
TA BlackRock Lifepath Index 2020 (R3CN)
TA BlackRock Lifepath Index 2025 (R3CQ)
TA BlackRock Lifepath Index 2030 (R3CS)
TA BlackRock Lifepath Index 2035 (R3CU)
TA BlackRock Lifepath Index 2040 (R3CW)
TA BlackRock Lifepath Index 2045 (R3CY)
TA BlackRock Lifepath Index 2050 (R3D2)
TA BlackRock Lifepath Index 2055 (R3D4)
TA BlackRock Lifepath Index 2060 (R3D6)
TOTAL FOR ALL INVESTMENT CHOICES

Authorization and Signature
I hereby authorize a payroll deduction of Plan contributions in accordance with the levels I have indicated. I understand this consitutes a "cash or deferred arrangement" under section 401(k) of the Internal Revenue Code and that my contributions are subject to the withdrawal restrictions of the Plan. By authorizing a payroll deduction, I understand I am electing to defer a portion of my salary to the Pediatric Advanced Therapy 401(k) Profit Sharing Plan and Trust. I understand that certain limitations are imposed on my constributions by Federal law and that my contributions may be refunded to comply with these laws. I further agree that neither Lolly Therapeutics LLC, the Plan Trustee, nor their affiliates will be liable for any loss when acting upon my instructions believed to be genuine.

I understand I have a duty to review my pay records (pay stub, etc.) to confirm the Plan Administrator has properly implemented my contribution election(s). Furthermore, I have a duty to infrom the Plan Administrator in writing if I discover any discrepancy between my pay records and the election(s) I have made in this Enrollment/Change Form. I understand I may modify my deferral rate prospectively, at the time I notify Plan Adminstrator in writing, consistent with the Plan terms.
Employee Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

401k Enrollment/Change Form For Full Time Employees

Employee Information

Contribution Amount

Before Tax Contribution

After Tax Contribution

Catch-Up Contributions

Investment Mix

Authorization and Signature