BY THIS AGREEMENT, made between _________________________ (Employee) and Boise State
University, the parties hereto agree as follows:
Effective for amounts paid on pay date __________________, 20____, which date is
subsequent to the execution of this Agreement, the Employee’s salary will be reduced by the amount
indicated below.
This agreement is legally binding and irrevocable for both Boise State University and the
Employee while employment continues. However, either party may terminate or otherwise modify
this Agreement 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.
The amount of Roth 403(b) salary reduction* shall be $___________per pay period
(biweekly). The amount specified above will be paid to _________________________ (retirement
vendor) as premiums on Supplemental Annuity Contract(s).
This amount will produce a total contribution that does not exceed the Employee’s statutory
limitation under IRC Section 415 or Section 402(g), whichever is less. For employees age 50 and
over, this amount will include any additional catch-up contribution permitted under IRC 414(v).
Signed this ______ day of _______________, 20____
Employee Signature
Employee ID Number
Boise State University Representative Date
*these limits are aggregated with contributions to the traditional 403(b) and the Persi Choice 401(K).
Please return to: 1910 University Drive •A-218 • Boise, ID •83725-1265
Phone: 208-426-1616 • Fax: 208-426-3100
