“Catch-Up” Election (Available only for plan years in which less than the maximum deferral was made by the participant)
I elect to use the 457(b) “catch-up” provision. I certify that I am now in my final three years of employment prior to my
scheduled year of retirement. My retirement date is scheduled for _____/_____/20_______. (REQUIRED) (Min Age 55, Max 70.5)
Deduct equal amounts of $______________ per pay period beginning with the __________, 20___ pay period.
Original Agreement
The undersigned hereby agrees to the terms and conditions of the Pensacola State College, Florida Deferred Compensation Plan (“Plan”) as such Plan now
exists or is hereinafter amended and a copy of the Plan has been made available to them. This election shall continue until the undersigned makes a
subsequent election as provided by the Plan.
I ( the Employee) understand and agree to the following:
My deferrals cannot begin sooner than the month following Participation Agreement approval. My accumulated deferrals will be held in trust by the Pensacola
State College, Florida for the exclusive benefit of participants and their beneficiaries until paid to me under the rules of the Plan. I realize I may not assign or
transfer my rights under the Plan.
I am responsible for the accuracy of the excludable amounts stated in this Agreement. Any overstatement of the amounts excludable as a salary reduction in
this agreement, or any other violation of the requirement of IRS Code Section 457 could result in additional taxes, interest, and penalties to the Employee.
I hereby authorize my Employer to reduce or suspend any deferrals established by this agreement, if in its opinion, the total annual deferral would exceed the
maximum allowable limit in any calendar year. Should my deferral exceed the maximum limit, I authorize my Employer to disallow deferral of the excess amount
and direct these amounts to be refunded to me.
Earnings, if any, will be applied to my accumulated deferrals in accordance with the Company and product I have selected. Neither the Employer, nor Trustees,
nor agencies of the Employer shall be liable for the performance of the Companies or products selected by the Employee.
Any change to this Agreement must be in writing to the Employer and becomes effective upon the execution of this Agreement by Employee and
Employer.
This Agreement may be terminated by either the Employer or Employee upon thirty (30) days notice to the Company and to the Employer or Employee as
applicable.
Effective Date of this Agreement ________________________________________, 20 ____.
_________________________________________________ Pensacola State College, Florida
AGENT / REPRESENTATIVE
_________________________________________________ By: ______________________________________________
EMPLOYEE EMPLOYER REPRESENTATIVE
Dated __________________________________ , 20______ Dated__________________________________ , 20_______
Important Notice- A copy of the account application must accompany this agreement and the following ownership and beneficiary designations must
be used:
Owner—”The Pensacola State College, Florida 457(b) Plan FBO (participant’s name)”
Beneficiary—Any single or multiple beneficiaries named by the participant. (Do not
list Pensacola State College, Florida as a beneficiary)
Copyright © 2010—TSA Consulting Group, Inc.
Pensacola State College, Florida
Participation Agreement for Internal Revenue Code
Section 457(b) Deferred Compensation Program
Name of Company—457(b) Product Provider
Position
Employee’s Name
Work Location
Employee Number
With respect to services rendered by the Employee hereafter, the Employer and the Employee hereby agree the Employee’s
compensation for such services shall be reduced by:
Equal amounts of $__________________________ per pay period beginning the ________________, 20___ pay period.
Amounts equal to ____________% of compensation per pay period beginning the ________________, 20 ___ pay period.
Amendment Agreement - Type of Change Desired
Increase from $______________ per pay period to $____________beginning the _______________, 20 ___ pay period.
Decrease from $_____________ per pay period to $____________beginning the _______________,20 ___ pay period.
Change to _______________ % of compensation per pay period beginning the ________________, 20 ___ pay period.
Suspend ________________________________________ Effective Date of Suspension____________, 20 ___
NAME OF COMPANY
