Instructions - 403-200 (05/2018)
PO Box 6980, West Jordan, UT 84084 ● (800) 274 0503 ext 5 ● Fax (800) 597-8206 ● www.NBSbenefits.com
403(b) Salary Reduction Agreement
Participant Instructions
The Salary Reduction Agreement (SRA) is utilized to establish, change, or cancel salary reductions withheld from your paycheck and contributed to the
403(b) Plan on your behalf. The SRA is also used to change the investment providers that receive your contributions. Upon completion, fax or mail a
copy of the form to National Benefit Services, LLC. Please note that this form is not valid unless all applicable sections are completed and you have
signed the form. If you have questions regarding this form, please call 1-800-274-0503 ext 5.
Upon completion, fax (1-800-597-8206), email, or mail a copy of the form to National Benefit
Services, LLC.
Please allow 5 business days for processing. Salary Reduction Agreements received less than 5 business days prior to the SRA due
date are not guaranteed to be processed for that SRA due date.
Important Information
The Employee agrees to indemnify and hold the Employer and National Benefit Services, LLC (NBS) harmless against any and all actions, claims, and
demands that may arise from the purchase of annuities or custodial accounts in this 403(b) Plan. The Employee acknowledges that neither the
Employer nor NBS have made representation to the Employee regarding the advisability, appropriateness, or tax consequences of the purchase of the
annuity and/or custodial accounts. The Employee agrees that neither the Employer nor NBS shall have any liability for any and all losses suffered by
the Employee with regard to his/her selection of the annuity and/or custodial account; its terms; the selection of the insurance company or regulated
investment company; the solvency of, 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.
The Employer reserves the right to alter terms of this Agreement as required to facilitate program compliance with state and federal law.
The Employer does not choose the annuity contract or custodial account in which the Employee's contributions are invested.
The Employee is responsible for setting up and signing the legal documents to establish the annuity contract or custodial account.
In order for the Employee to receive the expected tax results, the annuity contract or custodial account established must meet the requirements of
Section 403(b) of the Internal Revenue Code. It is solely the Employee’s responsibility to establish the proper type of contract or account for this
purpose.
The Employee is responsible for naming a death beneficiary under the annuity contract or custodial account. This is normally done at the time the
contract or account is established, although the designation should be reviewed from time to time.
The Employee is responsible for investment decisions, distributions, and any other transactions with the insurance company or investment company
and shall have total responsibility for all distributions and any resulting tax consequences. All rights under the contract or account are enforceable
solely by the Employee, the Employee’s beneficiary, or the Employee’s authorized representative.
The insurance or investment company may be required to receive approval from the Employer or National Benefit Services, LLC, prior to executing
certain transactions including loans, hardships, distributions, or transfers (as permitted by the Plan).
The Employee understands that information contained in this Agreement and other non-public information may be shared with the Employer's
designated third-party administrator in conjunction with the operation of the 403(b) Plan.
Retain a copy of this form for your records.
Form - 403-200 (12/2019)
PO Box 6980, West Jordan, UT 84084 ● (800) 274 0503 ext 5 ● Fax (800) 597-8206 ● www.NBSbenefits.com
403(b) Salary Reduction Agreement
1 Personal Information
Employer Name
Participant Mailing Address, City, State, Zip Code
Phone Number
Date of Birth
Date of Hire
Email Address
Social Security Number (required)
2 Salary Reduction
The Salary Reduction Agreement (SRA) is utilized to establish, change, or cancel salary reduction withheld from your paycheck and
contributed to the 403(b) plan on your behalf. Please check the appropriate box under Requested Action and list the beginning of
the month in which you intend your contributions to begin under the Effective Date. To change, begin, or cancel contributions, enter
your desired amount(s) and investment provider(s). This SRA will cancel and replace any previously submitted SRA. You
must list all new and existing deductions on this SRA form or they will be cancelled. The salary reductions identified in
the space below will be the only deductions performed starting on the Effective Date.
Investment Provider Name*
Monthly Dollar
Amount
Type of Deferrals
Requested Action
Effective
Date**
Pre-Tax
403(b)
Roth
403(b)
Other
$
New Existing
Change Cancel
1, 2020
$
New Existing
Change Cancel
1, 2020
$
New Existing
Change Cancel
1, 2020
Total Monthly Contributions
____________
*Please Note: Certain investment providers may not pay the administration fee. If you select an investment provider that
does not pay the administration fee, the fee will be deducted and paid from your salary reduction amount. Please
refer to the approved vendor list at www.nbsbenefits.com/403b for a current listing of providers that have agreed to pay the fee.
**Please submit the SRA to NBS 5 business days prior to the SRA due date to ensure your contributions begin as you intended.
3 Financial Advisor/Agent Information
Financial Advisor/Agent Name
Financial Advisor/Agent Phone Number
Financial Advisor/Agent Email Address
Financial Advisor/Agent Fax Number
4 Employee Approval
I understand and agree to the following:
1. This Salary Reduction Agreement (Agreement) is an agreement between me and my employer that I have entered into voluntarily.
2. This Agreement supersedes and replaces all prior Salary Reduction Agreements.
3. The Agreement is legally binding and irrevocable with respect to amounts paid or available while this agreement is in effect.
4. The Agreement may be terminated or modified at any time for amounts not yet paid or available.
5. Nothing herein shall affect the terms of my employment with the Employer.
6. This Agreement shall automatically terminate if my employment is terminated.
7. If the Salary Reduction Agreement is received less than 5 business days prior to the SRA due date, it is not guaranteed to be processed for that
SRA due date.
8. My salary reduction do not exceed contribution limits as determined by applicable law.
9. I am responsible for notifying my Employer if I own more than 50% of another business and adopt a retirement plan for that business to ensure I
have not exceeded the maximum contribution amount to all plans involved.
10. Any contribution that exceeds the maximum contribution limit must be distributed from my Employer’s 403(b) plan.
I authorize the automatic cancellation of this Salary Reduction Agreement in the event of any of the following: (1) if either my employer or National
Benefit Services, LLC (my employer’s third-party administrator) believe additional contributions will cause me to exceed limits under Code Section 415
or 402(g), (2) if I take a hardship distribution, if available, or (3) if I take an unforeseeable emergency distribution, if available.
I have read and understand the information contained on page 1 of this Agreement. I understand that by making this application the release of my
confidential information to third parties may occur as necessary to administer the Plan in accordance with the Internal Revenue Code.
Employee Signature
Date
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