Deferred Investment Financial Planning Professionals North Dakota Heartland Trust Company












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Employer:

Employee Information
First Name:	Last Name:
Address:	City: State: Zip:
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Social Security Number - Last Four Digits:

Date of Birth:
Date of Hire:

This Agreement will be effective for the pay period beginning:

	I elect to participate and contribute % of compensation per pay period on a pre-tax basis. (Maximum 75%)
	I elect not to make pre-tax contributions until further notice. I understand that if I do not participate now, or discontinue participation, I must wait until the next available enrollment date. Although I elect not to save through payroll deduction, I understand my employer may elect to contribute a discretionary contribution to the Plan, and I authorize such a contribution to be invested as indicated below.
Catch-up contributions
	I will be at least 50 years of age or older by the end of the calendar year and elect to make catch-up contributions to this plan. (The maximum catch-up contribution is $5,000 for 2006. You must max out the regular limit of $15,000 before the "catch-up" is available.)