10/26/20
Annual Leave Exchange Deferred Compensation Form
Check the box for the deferred compensation plan in which you participate and wish to send
Annual Leave Exchange money. If you are exchanging to more than one company, you will need
to complete a separate form for each.
Employee #: ____________________
Mass Mutual ICMA Nationwide VALIC
Complete the following:
I wish to exchange hours to deferred compensation. My hourly rate of pay is $ .
X $ = $ .
My normal per pay contribution is $ .
My total contribution will be $ + $ = $ for the 11/25/2020 paycheck.
Your regular per pay 457 contribution amount will remain the same until you change it by
completing and submitting a Deferred Compensation (457) Contribution Change Form.
Important note: Please keep in mind that your net pay will be affected by the 7.65% FICA tax and
the 3% FRS employee contribution that still must be deducted from the amount of your deferred
compensation contribution. No adjustments will be made to offset this from your take home pay.
EXAMPLE: I wish to exchange 40 hours to deferred compensation. My hourly rate of pay is $15.00.
40 hours X $15.00 = $600.00
My normal per pay contribution is $50.00. (If you do not want to contribute your normal per pay
amount, indicate zero on this line.)
My total contribution will be $600.00 + $50.00 = $650.00 for the 11/25/2020 paycheck.
Print name: Dept.:
Signature: Date: _____
Your completed, signed and dated form must be received no later than November 13, 2020. Send to:
Employees of the Board of County Commissioners, Business Technology Services, Clerk of the
Circuit Court & Comptroller, County Attorney, Human Resources, Office of Human Rights:
Submit by email to payroll@mypinellasclerk.org or by fax to (727) 464-8360
Employees of the Planning Council: Submit by email to info@ForwardPinellas.org
Employees of the Property Appraiser: Submit by fax to (727) 453-3536
Employees of the Supervisor of Elections: Submit by fax to (727) 453-3058
Employees of the Tax Collector: Submit by email to pctchradmin@taxcollect.com or fax to (727) 464-3413
