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Bonner Springs/Edwardsville USD 204
Bonner Springs USD 204 403(b) Plan
Notification Form
Approved Companies and Representatives:
Security Benefit
Teena Dreesen 913-962-9911
Terry Clark
913-962-9911
VALIC
Darla Haines Mills 913-752-7260
VOYA Retirement Ins. and Annuity
Sheri BIrdsell 913-469-8800
Primerica Shareholder Service
Steven Nelson 913-963-3612
3. Provide Signatures
I understand that I am eligible to participate in the Bonner Springs USD 204 Sec. 403(b) plan.
Signature of Participant
Date (mm/dd/yyyy)
1. Participant Information
Location
Plan Name
Bonner Springs USD 204 Voluntary Sec. 403(b) Plan
Participant Name
Male
Female
Last
Mailing Address
Street Address
City
Zip
Residental Address
(If different from mailing address)
Social Security Number
Street Address
City
Zip
Date of Birth
Date of Hire
Daytime Phone Number
Home Phone Number
2. I have been informed of the availability of the opportunity to participate in the voluntary
Sec. 403(b) offered through my employer.
I wish to participate in the Bonner Springs USD 204 403(b) Plan.
I am already participating in the Bonner Springs USD 204 403(b) Plan.
I choose not to participate in the Bonner Springs USD 204 403(b) Plan.