Fillable 403bSalaryReductionAgreement - 155631_06112010

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403bSalaryReductionAgreement - 155631_06112010

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Order #155631 6/11/2010
MAIL COMPLETED FORM TO:
ING Life Insurance and Annuity Co.
PO Box 990069
Hartford, CT 06199-0069
Telephone: 800-784-6386
403(b) PLAN
SALARY REDUCTION AGREEMENT
REV. 06/2010
www.CTdcp.com
Read the reverse side of this form carefully before completing this agreement. Please type or print clearly in ink. The Office of the
State Comptroller must approve all requests. You may not alter any of the printed information on this document. If you make a mistake,
you must complete a new form. All forms must be completed in their entirety.
New Participant 403(b) Change Request
Type of
Agreement
F I am a New
Participant
Date of Hire
F Name F Address F Deferral Amount Increase
F Deferral Amount Decrease F Suspend
Name & Address of Employing Agency
Social Security Number Department ID
Participant (last, first, middle initial) Former Name (if applicable)
Employee Number Employee Record
Number
Street Address Sex
F F F M
Date of Birth
City, State, Zip Code Office Telephone No. Home Telephone No.
Participant
Information
Please print
E-mail Address
Deferral
Amount
DEFERRAL AMOUNT: Deferral amount must be in whole dollars. Complete Catch-up Contribution Section below, if applicable.
I elect to defer from my total compensation $______________ per pay period, effective check dated _____/_____/_____
I understand my deferral election will remain in effect until I separate from State service, change or suspend my deferral amount by
completing a new Salary Reduction Agreement, the maximum annual limit is reached, or my deferrals are suspended following a
hardship withdrawal under the Plan.
Catch-Up
Contribution
Election
F AGE 50+ CATCH-UP OPTION – Available to employees who will be at least age 50 by December 31
st
of the calendar year.
I understand that 403(b) Plan (Plan) benefits are only payable (1) upon retirement or separation from State service; (2) due to disability as defined by the
Internal Revenue Code; (3) due to death or (4) for a financial hardship as defined in Section 403(b) of the Internal Revenue Code. THIS IS NOT A
SAVINGS ACCOUNT. I understand the Plan is administered in accordance with Section 403(b) of the Internal Revenue Code and any applicable
regulations. I acknowledge that as a Participant, I am solely responsible for any investment gain or loss, charge or expense of any kind under this Plan,
by virtue of my account upon which benefits under the Plan are based. I agree that neither the State, my Employing Agency, nor ING represents or
guarantees any tax consequence will occur because of my participation in this Plan and I shall be responsible to consult with and rely upon my own
legal, accounting or other representative concerning all questions about tax and investment consequences arising from my participation in this Plan. I
understand participation in this Plan is voluntary. In return, I, my heirs and successors hold harmless the State, my Employing Agency, its employees,
officials, assignees, and successors from any and all liability for all acts in good faith. I understand my deferral election can be suspended at any time
by completing a new Salary Reduction Agreement; however, compensation already deferred into the Plan cannot be withdrawn except for the benefit
payment reasons noted above.
Participant’s Signature
Date
Representative’s Signature
Rep Code Date
Official Use Only
F LPC
MAIL THE ORIGINAL SIGNED FORM TO THE ADDRESS INDICATED AT THE TOP OF THIS FORM
MAKE A COPY FOR YOUR RECORDS
O
f
f
ice of the State Comptrolle
r
(Authorized Signature/Date)
Order #155631 6/11/2010
Rev. 06/2010
Type of
Agreement
This agreement must be completed to enroll in the Plan, to make changes to an existing Salary Reduction Agreement or to
modify the amount of your deferral.
Employees who are employed by multiple 403(b) eligible agencies have the option to select which eligible agency(ies) and
corresponding job(s) their 403(b) Plan deferrals will be taken from. Therefore, all employees participating in the State of
Connecticut 403(b) Plan must provide their employee record number. Note that your employee record number is different from
your employee number. If you do not know your employee record number, you must contact your agency human resource or
payroll department in order to obtain the appropriate employee record number which corresponds to the job from which the Plan
deferrals will be taken. Forms will be returned if the employee record number is missing. If you are electing 403(b) deferrals
from more than one eligible agency and/or job, you must complete a separate Salary Reduction Agreement for each eligible
agency and/or job selected.
To designate a beneficiary or change a beneficiary designation, contact the Service Center at 1-800-584-6001 or visit
www.CTdcp.com
.
To apply for benefit payments/withdrawals or a financial hardship withdrawal, contact the Service Center at 1-800-584-6001.
If certain conditions are met, transfers to/from other plans or IRA’s may be allowed. For information, contact the Service Center
at 1-800-584-6001.
Deferral
Amount
Complete this section only if you are enrolling or changing your deferral amount (including electing to make Age 50+ Catch-up
contributions). Any amounts deferred must be made through payroll deductions from future compensation only.
Consult with your Plan Registered Representative (Registered Representative) regarding restrictions that may apply if you
participate in any other salary reduction plan, such as a Roth 403(b) plan, a 457 plan and/or a 401(k) plan.
Unless you specifically elect and use the Age 50+ Catch-up option, the maximum amount you can defer in any calendar year is
the amount specified under Section 402(g) of the Internal Revenue Code (as adjusted for cost of living). If you are making both
403(b) and Roth 403(b) Plan contributions, your aggregate contributions cannot exceed the maximum annual limit. Your
Registered Representative can help establish the limitation applicable to your individual situation; however, it is ultimately your
responsibility to assure that you do not defer more than is allowed in any calendar year.
The effective check date of any enrollment or change of deferral amount is the date indicated or the earliest date thereafter
consistent with the Administrator’s processing requirements and the provisions set forth in Section 403(b) of the Internal
Revenue Code.
Catch-Up
Contribution
Election
The Age 50+ Catch-up contribution is available to those participants who are or will be at least age 50 by December 31
st
and
who have elected to defer the maximum amount under Section 402(g) of the Internal Revenue Code, as adjusted for cost-of-
living.
Participant
Signature
Your signature acknowledges (1) that you have received and read an investment option summary or a prospectus for each of the
investment options you have elected to invest in; (2) that the State, your Employing Agency and its agents are not required to
invest deferred compensation in any manner whatsoever. You understand that participation in the State of Connecticut 403(b)
Plan is voluntary. In return, you, your heirs, successors and assignees shall hold harmless the State of Connecticut and its
employees, officials, agents, assignees and successors from any and all liability for all acts in good faith.
THIS IS NOT A SAVINGS ACCOUNT. THIS IS A 403(b) RETIREMENT PLAN.
Keep a copy of this Agreement for your records. Return the original signed form to your Registered Representative or to the address
shown on the front of this form.
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