Print Name_____________________________
Start Deduction Month/Yr_________________
P.O. Box 2098, Everett, WA 98203
SALARY REDUCTION AGREEMENT FOR
403(b)(1) AND 403(b)(7) PROGRAMS
IMPORTANT NOTICE
Before you sign: Read the important information on the reverse side of this form. Each Employee who initiates or changes contributions to a 403(b) program shall, at such time, provide the Employer with a copy of his/her maximum exclusion allowance (MEA) as calculated by the Employee’s chosen annuity or custodial account provider or any other party acceptable to Employer. For each Employee contributing the maximum or more, utilizing the “catch - up provisions” or the special elections allowed by the Internal Revenue Code, an MEA calculation shall be required annually. A copy of such MEA shall be provided to Employer by November 1 of each calendar year in which the “catch-up – provisions” or “special elections” are utilized.
Implementation Date: Salary reduction instructions shall be implemented in accordance with Employer’s administrative schedule. Select all that apply
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ACTION: [ ] Start [ ] Change [ ] Catch-Up Provision (provide MEA)
Service Provider: ________________________________Amount $___________ per month
Service Provider:________________________________Amount $___________ per month
Service Provider:________________________________Amount $___________ per month
[ ] Stop Service Provider: ______________________________________
The above named Employee agrees to modify his/her salary as indicated above. Employer agrees to contribute this amount on Employee’s behalf into an annuity or custodial procedures.
Employee is responsible for determining that the salary reduction amount does not exceed the limits as set forth in Applicable Law. Furthermore, Employee agrees to indemnify and hold Employer harmless against any and all actions, claims and demands whatsoever that may arise from the purchase of annuities or custodial accounts for Employees in amounts in excess of contribution limits as defined under Applicable Law except where an MEA was calculated by Service Provider based on accurate information provided by Employee.
Employee acknowledges that Employer has made no representation to Employee regarding the advisability, appropriateness or tax consequences of the accounts selected by Employee. It is intended that requirements of all applicable state or federal income tax rules and regulations (Applicable Law) will be met. The Employee understands and agrees to the following:
1. this Salary Reduction Agreement is legally binding and irrevocable with respect to amounts paid or
available while this agreement is in effect;
2. this Salary Reduction Agreement may be terminated at any time for amounts not yet paid or available, and
that a termination request is permanent and remains in effect until a new Salary Reduction Agreement is
submitted; and
3. this Salary Reduction Agreement may be changed with respect to amounts not yet paid or available in
accordance with the Employer’s administrative procedures.
Employee is responsible for determining that salary reduction amount does not exceed the limits set forth in Applicable Law. Furthermore, Employee agrees to indemnify and hold harmless against any and all actions, claims and demands whatsoever that may arise from the purchase of annuities or custodial accounts for Employees in amounts in excess of contribution limits as defined under Applicable Law except where an MEA was calculated by Service Provider based on accurate information provided by Employee.
Employee acknowledges that Employer has made no representation to Employee regarding the advisability, appropriateness or tax consequences of the purchase of the annuity and/or custodial account described herein. Employee agrees Employer shall have no liability whatsoever for any and all losses suffered by the Employee with regard to hi/her selection of annuity and/or custodial account; its terms; the selection of the insurance company or regulated investment company; the financial condition, operation of or benefits provided by said insurance company or regulated investment company; or his/her selection and purchase of shares of regulated investment companies. Nothing herein shall affect the terms of employment between the Employer and Employee. This agreement supersedes all prior salary reduction agreements and shall automatically terminate if Employee’s employment is terminated.
continued
IMPORTANT INFORMATION
1. Employer does not choose the annuity contract or custodial account in which your contributions are invested.
2. Employees are responsible for setting up and signing the legal documents to establish your annuity contract
or custodial account. However, in certain group annuity contracts, the Employer is required to establish the contract.
3. In order to receive the expected tax results, Employees are responsible for investing in annuity contracts or custodial accounts that meet the requirements of Section 403(b) of the Internal Revenue Code.
4. Employees are responsible for naming a death beneficiary under annuity contracts or custodial accounts. This is normally done at the time the contract or account is established. Beneficiary designations should be reviewed periodically.
5. Employees are responsible for all distributions and any other transactions with the Service Provider. All rights under contracts or accounts are enforceable solely by Employee, Employee beneficiary or Employee’s authorized representative. Employee must deal directly with Service Provider to make loans, transfer to different contracts or custodial accounts, begin distributions, or any other transactions.
6. Employees are responsible for determining that salary reductions do not exceed the allowable contribution limits under Applicable Law. You are strongly encouraged to have annual maximum exclusion calculations performed by your chosen Service Provider.
I certify that I have read this complete agreement and that my salary reductions do not exceed contribution limits as determined by Applicable Law. I understand my responsibilities as an Employee under this Program, and I request that Employer take the action specified in this agreement. I understand that all rights under the annuity or custodial account established by me, under the Program are enforceable solely by me, my beneficiary or authorized representative.
_________________________________________ __________________
Employee Signature Date
_________________________________________
Employee Social Security Number
I agree to comply with all pertinent written directives regarding solicitation of Employees. I will provide a maximum exclusion allowance (MEA) calculation for each Employee who initiates or changes contributions. An MEA calculation will be provided annually for Employee contributing to the maximum limitation or more or utilizing “catch-up provisions” or the special elections. Furthermore, I agree to indemnify and hold harmless the Employer, any individual member of governing board and the Employee participating in the 403(b) Program against any claims based on an error in the MEA I provided, except where the error is based upon erroneous information provided by Employer or Employee.
(Please Print)
_________________________________________
Sales Agent/Representative Name
_________________________________________
Phone
_________________________________________
Address
_________________________________________ __________________
Signature Date
Employer hereby agrees to this Salary Reduction Agreement.
________________________________________ __________________
Payroll Manager Signature Date
Payroll Manager
Title
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Rev. 7/11 5.04c