• 401k Enrollment/Change Form For Full Time Employees

    Pediatric Advanced Therapy 401(k) Profit Sharing Plan and Trust 809558-000
  • Employee Information

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  • * 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 $ Or % of my eligible pay on a before tax-basis (minimum contribution amounts are 3% or $50/paycheck).

  • After Tax Contribution

  • I wish to contribute $ Or % 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 $ Or %per 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.
  • 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.
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  • 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.

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