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Questions? Call our Service Center at 1-888-796-3786, Option (Town of Lunenburg)

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SRA_NoRoth_Dollar Rev. 01.01.2019
Questions? Call our Service Center at 1-888-796-3786, Option 5
Use this form to set up or change contributions to your 403(b) Account. Please type or print your information and fax to 1-866-908-7582
Employee Data – ALL FIELDS REQUIRED
Employer Name:
Name:
Social Security #:
Address:
City/State/Zip:
Daytime Phone #:
Date of Birth:
Evening Phone #:
Date of Hire:
Email Address:
# of Salary Reductions:
Complete this section to set up or change contributions to your 403(b) Account. Please note that the contribution amount may not
exceed the maximum allowable limits as determined by the Internal Revenue Code. Review your Plan Highlights for the availability of
Age 50 or 15 Years of Service Catch-up Contributions. Click to view the Maximum Amount Contributable (MAC) limits for the current
tax year.
Start new payroll deductions (Account must be established under your current employer’s plan prior to submitting
SRA fill in Account Number below).
Increase existing payroll deductions. Decrease existing payroll deductions.
One-time payroll deduction then stop deductions. One-time payroll deduction then revert to existing deductions.
Change investment providers. Stop contribution to and start contributions to .
Please stop my contributions to .
Make changes effective with payroll date .
You are responsible for establishing any annuity contract or custodial account with the Investment Provider(s) indicated below prior to
submitting your Salary Reduction Agreement. Please provide your account # to avoid delay in processing your changes.
Investment Provider(s)
Account #
Annual Salary Reduction
Salary Reduction Per Pay Period
1.
$
$
2.
$
$
3.
$
$
4.
$
$
Total deduction each pay period $
After the initial SRA is submitted and approved by TSA Consulting Group, Inc., subsequent changes can be made online at https://sra.tsacg.com.
Any changes to 403(b) deferrals can occur no earlier than the first pay period following the date the agreement is received.
This Salary Reduction Agreement is irrevocable with respect to amounts earned while it is in effect and applies only to amounts earned
after the agreement becomes effective.
This Salary Reduction Agreement will continue until amended or terminated. This agreement shall automatically terminate with severance
from employment.
The Employee agrees that the Employer shall have no liability whatsoever for any loss suffered by the Employee with regard to his/her
selection of an investment provider, or the solvency of the operation of, or benefits provided by, said investment provider.
Signature of Employee Date (Please Note: Above date must be within last 90 days to be valid)
Salary Reduction Agreement
Contribution Specifications
Approval Signature
TSA Consulting Group, Inc., Attn: SRA Processing Team
P.O. Box 4037, Fort Walton Beach, FL 32549
Toll Free: 1-888-796-3786, Option 5 • Toll Free Fax: 1-866-908-7582
Email: sraprocessing@tsacg.com
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Questions Call our Service Center at 1-888-796-3786, Option (Town of Lunenburg)

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Completed 4 August 2020

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