Terminal Pay at Retirement or Termination
This Agreement shall be legally binding and irrevocable with respect to amounts earned while the Agreement is in effect, and any termination of this
Agreement shall be effective only with respect to amounts not yet earned at the time of said termination. It is provided that this reduction does not
exceed the Employee’s statutory limits under Section 402(g) or the limitation of Section 415 of the Internal Revenue Code. This limits the total allowable
salary reduction to all Companies to which salary reduction contributions can be made. It is understood that the amount specified will be forwarded to
the Company listed above, provided that the Employee has sufficient earnings during the immediately preceding pay period to accommodate the
requested reduction. In the event that the calculations provided by the District are lower that the calculations provided by the company / representative,
the District’s calculation shall prevail.
I hereby authorize my Employer to reduce or suspend any contributions established by this agreement, if in its opinion, the total annual contributions
would exceed my Maximum Allowable Contribution in any calendar year.
The Employee is 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 Section 403(b) could result in additional taxes, interests, and penalties to
the Employee.
It is the intent of the parties that the non-forfeitable retirement deferred annuity or custodial contract pursuant to this Agreement shall qualify for the
Federal Income Tax benefits provided for in Section 403(b) of the Internal Revenue Code of 1954, as amended. 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
_________________________________________________
________________________________________________
EMPLOYEE EMPLOYER
Dated ___________________________________ , 20 ______ Dated _________________________________ , 20 ______
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.
The amount elected above shall result in a total ANNUAL REDUCTION not to exceed the maximum allowable contribution calculation. The
Employer agrees that it will remit the amount of such reduction for the 403(b) Tax Sheltered Annuity or 403(b)(7) custodial account offered
by the Company listed above.
Position
Employee’s Name
Work Location
Employee Number
Pensacola State College, Florida
Payroll Reduction Authorization for 403(b)
Annuity Contract or 403(b)(7) Custodial Account
Original Agreement
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—Name of Company ___________________________________________________
Effective Date of Change __________________________________, 20 _____
I have read the above and understand the proposed change. I hereby request that such change be effected. I realize that if the change
results in decrease or elimination of reduction under the 403(b) T.S.A.
program, that this reduction or elimination cannot be “made up” in the
future unless it falls within the allowable limits for that year.
One-time reduction from Terminal Pay $__________________
Total from Terminal Pay
The Employee expressly understands and agrees that if the amount requested above is more than the amount due to the Employee (less
applicable taxes), no reduction will be made and the entire amount will be paid to the Employee.
Copyright © 2011 TSACG, Inc.
Name of Company
No Load Account (No Agent Signature or Product Disclosure Form Required)
Low Fee Account
