University of West Georgia
SALARY REDUCTION AGREEMENT
(check one)
403b 457b
Agreement made this _____ day of ____________________, 20__, by and between
University of West Georgia (employer) and ______________________________ (employee).
Whereby employer and employee agree as follows:
The monthly or biweekly (check one) salary of the employee shall be
reduced by $__________ beginning ____________________, 20__.
THE AMOUNT OF THE REDUCTION SHALL BE PAID BY THE EMPLOYER TO:
________________________________________ (annuity company).
Employee’s Signature
SS#
Date of Birth
NOTE: This is NOT an enrollment form. If you are not currently a member of a TSA company,
please complete an enrollment form from the company in which you wish to participate.
Human Resources Use Only
Benefits representative must approve PRIOR to processing in payroll.
UWG Benefits Representative
