_________________________________________________ ________________________
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Louisiana State University
Office of Accounting Services
Payroll
204 Thomas Boyd Hall
SALARY REDUCTION AUTHORIZATION AS160
This transaction will affect your Federal income tax and should be discussed with your tax advisor. IRS regulations require contributions to the pre-tax 403(b) and
the Roth 403(b) post-tax deductions to be aggregated when determining contribution limits.
Change in Current Enrollment: Increase Decrease
Change Annuity or Mutual Fund Company (letter must be attached to cancel other company)
Other ______________________________________________________________________
I hereby authorize the University to reduce my annual salary by $__________________ (not less than $200) effective with the payroll period beginning
________________________, with the understanding that an amount corresponding to the total annual salary reduction will be paid by the University during the
period of such reduction to:
PRE – TAX DEDUCTIONS POST –TAX DEDUCTIONS
Fidelity Investments
VALIC (Mutual Fund product)
TIAA-CREF
$_________
$_________
$_________
Roth 403(b) Fidelity
Roth 403(b) VALIC
Roth 403(b) TIAA-CREF
$_________
$_________
$_________
Other (grandfathered vendor) _____________________ $_________
Installments of $____________ per paycheck (26 wage, 12 for salary, 9 or 12 for academic) for the purchase of retirement annuities or shares issued by a regulated
investment company. The amount indicated above will produce a total contribution that does not exceed my elective deferral limit under IRC Section 402(g) or the
limitations of IRC Section 415(c). It is understood that the responsibility for authorizing an exclusion in excess of the legally allowable amount shall be mine and that
any tax liability and/or penalties resulting therefrom will be borne by me. This agreement shall be legally binding and irrevocable while the agreement is in effect.
However, it may be terminated or otherwise modified as of the end of any pay period by giving at least thirty days written notice so that this agreement will not apply
to salary subsequently paid.
Employee ______________________________________________ LSU ID ____________________________________________
Signature ______________________________________________ Date ___________________________________________
COMPANY REPRESENTATIVE:
Please indicate your annuity or mutual fund agent: __________________________________________
Have you participated in a salary reduction plan with another University to purchase retirement annuities or shares issued by a regulated investment company
during the current year? YES NO
Are you currently employed by any other organization, including self-employment?
YES NO
If YES, (a) Are you participating in a salary reduction plan [401(k), SARSEP, 403(b), SIMPLE] with this organization? YES NO
If YES to past contributions: (a) Dates ________________ to __________________ (b) Year-to- Date Contributions _____________________________________
(c) University or Organization____________________________________________
You will find authorization above for the purchase of retirement annuities or shares issued by regulated investment company by this organization from your company
to provide retirement benefits for one of our employees. This is an organization as described in Section 501(c)(3) and is exempt from tax under Section 501(a) of
the Internal Revenue Code.
University Official’s Signature Date
FOR ACCOUNTING SERVICES USE ONLY
Rev 05/19
