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Deduction Authorization Form for Enrollment/Change/Cancellation in:
FIDELITY INVESTMENTS 403(b) Supplemental Retirement Plan (SRA)
Please print or type all information in BLACK INK for electronic imaging.
Payroll System Check One: Regular Contract University of Maryland
Human Resources/Payroll Agency Code
(See your pay stub for this information) Institution Name (Place of Employment)
Social Security Number Employee Name
Important Notes: This form is used to establish or change the employee’s elected contribution
amount for biweekly deductions. This form is valid only when signed by both the employee and the
Institution Benefits Coordinator.
Deduction Action Requested Name of SRA Plan CPB Deduction Code Payroll Cycle
FDLTY 403(b) 68
Deduction will begin on
the next available pay
period upon receipt of
this form at the State
Central Payroll Bureau.
Employee Total Biweekly Deduction Amount
Current Amount $
New Amount $
Effective upon receipt at the State Central Payroll Bureau, I authorize the State of Maryland to
deduct from my salary the above amount and forward it to the company listed. This authorized
amount is to continue until a change is submitted by me to my Institution Benefits Coordinator on a
new authorization form. Timing for the application of this action is dependent upon when it is
received by the State Central Payroll Bureau.
Employee’s Signature Date Place of Employment
(In the case of an initial enrollment, my signature below assures that I have forwarded an employee-signed 403(b)
enrollment form to the FIDELITY INVST vendor, prior to this form being submitted to the UM System Payroll/Central
Payroll Bureau. Upon receipt of the form, the vendor shall notify the Benefits Coordinator immediately via FAX.)
Benefits Coordinator’s Signature Date Benefits Coordinator’s Phone Number
I:public\forms\optional supplement\Ded Form FIDELITY INVESTMENTS 403(b) (CPB September 29, 2004)