403(b) Plan Employee Elective Contribution Election
Employee agrees to make employee elective contributions to the 403(b)
plan as follows:
Commencing on ______________________
Date (MM/DD/YYYY)
A. $_____________ each pay period, (_______ pay periods per year).
B. ______ % of compensation for each pay period (______ pay
periods per year).
The frequency with which a 403(b) Plan Employee Elective Contribution
Agreement may be entered into or amended, the compensation as to
which such agreement applies, and the ability to revoke such agreement
shall be determined under the federal income tax rules applicable to
qualified cash or deferred arrangements.
457(b) Plan Employee Elective Contribution Election
Employee agrees make employee elective contributions to the 457(b) plan
as follows:
Commencing on ______________________*
Date (MM/DD/YYYY)
A. $_____________ each pay period, ( ______ pay periods per year).
B. ______ % of compensation for each pay period ( ______ pay
periods per year).
* If the commencement date is earlier than the first day of the month
following the date of this agreement, such date will be the first day of
the month after the date of this agreement.
Your employer sponsors a 403(b) plan and a 457(b) plan. To participate in either or both plans, you must complete this form, even if in the past you completed a
similar agreement for one of the plans. This agreement will replace any prior employee elective contribution agreement under the 403(b) plan and/or 457(b) plan.
Please indicate to which plan this agreement applies: Check One:
403(b) 457(b) Both New Enrollment Contribution Amount Change
EMPLOYER: _____________________________________________________________________
1. EMPLOYEE INFORMATION
Name: ___________________________________________________________________________ SSN: __________________________________
Address: _________________________________________________ City: ________________________ State: _______ ZIP: ___________
Date of Birth: _____________________ Phone: ____________________________________________ Date of Hire: ______________________
Employee #: ______________________ GA #: __________________________ Present Annual Salary: $ ________________________________
2. AGREEMENT/AUTHORIZATION
This agreement is made by and between Employer and Employee. The parties agree to and acknowledge the following:
403(b) Plan and 457(b) Plan
Employee Elective Contribution Agreement
VL 14118 VER 4/2012 Original – Employer, Copy – Employee 1.0 page 1 of 1
The Variable Annuity Life Insurance Company (VALIC), Houston, Texas
• Employee requests that the Employer invest the employee elective contributions in an annuity contract meeting the requirements of IRC Section 403(b) or
457(b), as applicable, issued by The Variable Annuity Life Insurance Company.
• This agreement shall terminate any prior employee elective contribution agreement executed between the Employer and the Employee under the
Employer’s Section 403(b) or 457(b) plans. This agreement shall continue indefinitely until amended or terminated by either party by giving at least
thirty (30) days written notice prior to the date of such amendment or termination. If Employer elects to cease all employee elective contributions to its
plans, this agreement shall automatically terminate. Unless the Employer’s plan provides otherwise, this agreement shall automatically terminate upon
the Employee’s separation from service with the Employer.
• Employee may only contribute amounts that have not already been paid or made available. Employee agrees and acknowledges that contributions shall not
exceed applicable limits under the plan or federal law and that Employer may limit contributions in order to comply with federal law and the plan document,
if any. Employee hereby directs that any contribution in excess of such limits be returned to Employee in accordance with governing legal requirements.
• The Employee agrees and acknowledges that contributions under this agreement shall be subject to the provisions of the respective plans and that the
Employer may impose its own or additional administrative rules and procedures.
• Nothing in this agreement shall be deemed to constitute an employment agreement and nothing contained herein shall be deemed to give the Employee
any right to be retained in the employ of the Employer.
_____________________________________________ __________________ _____________________________________ _________________
Employee Signature Date Employer Signature Date
By: ____________________________________________________
Title: ___________________________________________________
For customer assistance, contact VALIC at:
P.O. Box 15648
Amarillo, TX 79105-5648
or call 1-800-448-2542
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signature
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