Fillable Form 155631 403(b) PLAN SALARY REDUCTION AGREEMENT connecticut

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Form 155631 403(b) PLAN SALARY REDUCTION AGREEMENT connecticut

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Order #155631 09/01/2014
403(b) PLAN
SALARY REDUCTION AGREEMENT
REV. 09/2014
www.CTdcp.com
MAIL COMPLETED FORM TO:
Voya Financial™
PO Box 990069
Hartford, CT 06199-0069
Telephone: 800-784-6386
Read the
r
e
v
erse side o
f
this form carefully before completing this ag
r
eement. Please t
y
pe o
r
print clearl
y
in ink. The Office o
f
the
State Comptroller must approve all requests. You may not alter any of the printed information on this document. If you make a mistake,
you must complete a new form. All forms must be completed In their entirety.
Type of
Agreement
New Participant 403(b) Change Request
I am a New
Participant
Date of Hire
Name Address Deferral Amount Increase
Deferral Amount Decrease Suspend
Participant
Information
Please print
Name & Address of Employing Agency
Social Security Number Department ID
Participant (last, first, middle initial) Former Name (if applicable)
Employee Number Employee Record
Number
Street Address Sex
F M
Date of Birth
City, State, Zip Code Office Telephone No. Home Telephone No.
Personal E-mail Address
Deferral
Amount
DEFERRAL AMOUNT: Deferral amount must be in whole dollars. Complete Catch-up Contribution Section below, if applicable.
PRE-TAX DEFERRAL - I elect to defer from my total compensation, $______________ per pay period, effective
check dated _____/_____/_____
POST-TAX (ROTH) DEFERRAL - I elect to defer from my total compensation, $______________ per pay period, effective
check dated _____/_____/_____
Catch-Up
Contribution
Election
AGE 50+ CATCH-UP OPTION – Available to employees who will be at least age 50 by December 31
st
of the calendar year.
I understand my deferral election will remain in effect until I separate from State service, change or suspend my deferral amount by completing a new
Salary Reduction Agreement, the maximum annual limit is reached, or my deferrals are suspended following a hardship withdrawal under the Plan. I
understand that 403(b) Plan (Plan) benefits are only payable (1) upon retirement or separation from State service; (2) due to disability as defined by the
Internal Revenue Code; (3) due to death or (4) for a financial hardship as defined in Section 403(b) of the Internal Revenue Code. THIS IS NOT A
SAVINGS ACCOUNT. I acknowledge receipt of the Plan document and confirm I understand the terms, provisions and conditions thereof; which terms
provisions and conditions are hereby incorporated into this Participation Agreement and constitute my entire rights and obligations under the Plan. I
understand the Plan is administered in accordance with Section 403(b) of the Internal Revenue Code and any applicable regulations. I acknowledge that
as a Participant, am solely responsible for any investment gain or loss, charge or expense of any kind under this Plan, by virtue of my account upon
which benefits under the Plan are based. I agree that neither the State, my Employing Agency, nor Voya Financial™ represents or guarantees any tax
consequence will occur because of my participation in this Plan and I shall be responsible to consult with and rely upon my own legal, accounting or
other representative concerning all questions about tax and investment consequences arising from my participation in this Plan. I understand
participation in this Plan is voluntary. In return, I, my heirs and successors hold harmless the State, my Employing Agency, its employees, officials,
assignees, and successors from any and all liability for all acts in good faith. I understand my deferral election can be suspended at any time by
completing a new Salary Reduction Agreement; however, compensation already deferred into the Plan cannot be withdrawn except for the benefit
payment reasons noted above.
Participant’s Signature
Date
Representative’s Signature
Rep Code Date
Official Use Only
LPC
MAIL THE ORIGINAL SIGNED
FORM
TO
THE
ADDRESS INDICATED
AT THE
TOP OF THIS FORM. MAKE
A COPY FOR
YOUR
RECORDS
Order #155631 09/01/2014
Rev. 03/2012
Type of
Agreement
This agreement must be completed to enroll in the Plan, to make changes to an existing Salary Reduction Agreement or to
modify the amount of your deferral.
Employees who are employed by multiple 403(b) eligible agencies have the option to select which eligible agency(ies) and
corresponding job(s) their 403(b) Plan deferrals will be taken from. Therefore, all employees participating in the State of
Connecticut 403(b) Plan must provide their employee record number. Note that your employee record number is different from
your employee number. If you do not know your employee record number, you must contact your agency human resource or
payroll department in order to obtain the appropriate employee record number which corresponds to the job from which the Plan
deferrals will be taken. Forms will be returned if the employee record number is missing. If you are electing 403(b) deferrals
from more than one eligible agency and/or job, you must complete a separate Salary Reduction Agreement for each eligible
agency and/or job selected.
Deferral
Amount
Complete this section only if you are enrolling or changing your deferral amount (including electing to make Age 50+ Catch-up
contributions). Any amounts deferred must be made through payroll deductions from future compensation only.
Consult with your Plan Voya Registered Representative (Registered Representative) regarding restrictions that may apply if you
participate in any other salary reduction plan, such as a Roth 403(b) plan, a 457 plan and/or a 401(k) plan.
Unless you specifically elect and use the Age 50+ Catch-up option, the maximum amount you can defer in any calendar year is
the amount specified under Section 402(g) of the Internal Revenue Code (as adjusted for cost of living). If you are making both
403(b) and Roth 403(b) Plan contributions, your aggregate contributions cannot exceed the maximum annual limit. Your
Registered Representative can help establish the limitation applicable to your individual situation; however, it is ultimately your
responsibility to assure that you do not defer more than is allowed in any calendar year.
The effective check date of any enrollment or change of deferral amount is the date indicated or the earliest date thereafter
consistent with the Administrator’s processing requirements and the provisions set forth in Section 403(b) of the Internal
Revenue Code.
Catch-Up
Contribution
Election
The Age 50+ Catch-up contribution is available to those participants who are or will be at least age 50 by December 31
st
and
who have elected to defer the maximum amount under Section 402(g) of the Internal Revenue Code, as adjusted for cost-of-
living.
Distributions
To apply for benefit payments/withdrawals or transfer to/from other plans or IRA’s, contact Customer Service at 1-800-584-6001 or
visit www.CTdcp.com.
Participant
Signature
Your signature acknowledges (1) receipt of the State of Connecticut Deferred Compensation 403(b) Plan document and
agreement to the terms, provisions and conditions thereof; which terms, provisions and conditions are hereby incorporated into this
Participation Agreement and constitute your entire rights and obligations under the Plan; (2) that you have received and read an
investment option summary or a prospectus for each of the investment options you have elected to invest in; (3) that the State,
your Employing Agency and its agents are not required to invest deferred compensation in any manner whatsoever. You
understand and acknowledge that all Plan assets shall be held in trust for the exclusive benefit of the Participant in accordance
with the Plan document and the Internal Revenue Code. You understand that participation in the State of Connecticut 403(b) Plan
is voluntary. In return, you, your heirs, successors and assignees shall hold harmless the State of Connecticut and its employees,
officials, agents, assignees and successors from any and all liability for all acts in good faith.
THIS IS NOT A SAVINGS ACCOUNT. THIS IS A 403(b) RETIREMENT PLAN.
Beneficiary
Designation
If you have experienced a marriage, divorce or other life changes since your initial enrollment or want to update your beneficiary
designation, contact Customer Service at 1-800-584-6001 or visit www.CTdcp.com. If you fail to designate a beneficiary, your 403b
benefits will be paid to your estate in the event of your death.
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Form 155631 403(b) PLAN SALARY REDUCTION AGREEMENT connecticut

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