Employee: E#:
Effective Date: Payroll Frequency: Total:
Employee's Approval: Employer's Approval:
Signature/Date Signature/Date
Memorandum Notations:
1. Section 415(c)(4) Election
None
(A) Year of Separation
(B) Catch-up 25% + $4,000
(C) Apply Section 415 Only
2. Other:
This agreement shall be legally binding and irrevocable as to each of the parties hereto while employment continues; provided, however, that either party
may terminate this agreement as of the end of any pay period, so that it will not apply to salary subsequently earned, by giving written notice prior to the
beginning of such pay period of the date of termination
Both parties hereby acknowledge that this agreement is intended to qualify amounts involved for salary deferral. It is the parties intent that the annuities
purchased, the determination of limitations or exclusion allowance and other matters directly related to the administration of the employer's deferred
compensation plan be consistent with Sections 403(b) and 415 of the Internal Revenue Code and all related regulations, rulings or other authoritative
provisions, in addition to the employer's administrative rules and procedures. Employer shall have the right to unilaterally terminate this agreement if
employer has reason to believe continued salary reductions would cause excess contributions, per Internal Revenue service provisions, to result from
continuation. Employer shall have the right with or without seeking employee's advice to direct any company named above to refund to employee any
excess contributions as such are defined by Internal Revenue service.
In consideration of execution by employer of this agreement, employee hereby agrees to indemnify and hold harmless and release employer and its
trustees, officers, and employees, from all claims and liability of any type directly or indirectly arising out of this agreement. Employee acknowledges
awareness that participation in certain deferred compensation arrangements with another employer could result in disallowance of deferral of some or all of
above amounts. Employee certifies that any and all prior year's participation in a Section 457 plan has been disclosed in writing to employer, as well as
any previous election under Section 415(c)(4).
Execution of this agreement does hereby cancel any agreements for salary reductions previously executed by employee for the employer's 403(b) tax-
deferred annuity plan. This agreement supersedes and replaces all such prior agreements.
By this agreement made between East Tennessee State University (employer) and the employee named above, the parties hereto agree as follows:
Employee does hereby request and employer does hereby agree to reduce the salary of employee by the amount(s) indicated below and to pay such
amount(s) to he company(s) as indicated below for the purpose of purchasing for the employee an annuity qualifying under the terms of Section 403(b) of
the Internal Revenue Code.
Company Name Company Code Amount Per Pay Period Annual Amount
Participation Agreement for Section 403(b) Tax-Deferred Annuity
