By signing this Agreement, Employee agrees to modify his/her salary as indicated above and Employer agrees to contribute this amount on
Employee’s behalf into the applicable Plan investments selected by Employee with the proper identification of pre-tax contributions and after-tax
contributions to aid in proper allocation to segregated accounts by the Provider(s). It is intended that the requirements of all applicable state and
federal tax rules and regulations (Applicable Law) will be met.
The Employee understands and agrees that this Agreement:
1. Is legally binding and irrevocable with respect to amounts paid or available while it is in effect; 2. May be terminated at any time for amounts
not yet paid or available, and that a termination request is permanent and remains in effect until a new salary reduction agreement is
submitted; 3. Is effective only for amounts not yet earned or made available in accordance with the Employer’s administrative procedures.
Employee further agrees that:
He/she may be assessed fees associated with administering the Plan either directly by the product vendor or by payroll deduction. He/she is
responsible for determining that his/her salary reduction amount does not exceed the limits of the Applicable Law and is further responsible for
the requirement that any after-tax contributions to a Roth option be segregated into a separate account that is separately tracked and monitored.
He/she is responsible for the accuracy of the information provided by Employee, which is used in determining Employee’s maximum annual
contribution limit; and Employer has no liability for any losses suffered by Employee that result from his/her participation in the Plan.
Employee acknowledges that Employer has made no representation to Employee regarding the advisability, appropriateness or tax
consequences of the Plan investment(s) selected by the Employee. Nothing herein shall affect the terms of employment between Employer
and Employee.
This agreement supersedes all prior salary reduction agreements and shall automatically terminate if your employment with the Employer is
terminated.
Important Information
1. Employer does not choose any products in which contributions are invested nor does it endorse, promote or
in any way guarantee any investments in the Plan.
2. Employees are responsible for setting up and signing the legal documents to establish the annuity contract or custodial account. However,
in certain group annuity contracts, Employer may be required to establish the contract.
3. In order to receive the expected tax results, Employees are responsible for investing in appropriate products that meet the
requirements of the applicable Sections of the Internal Revenue Code.
4. Employees are responsible for naming a death beneficiary under the applicable Plan. This is normally done at the time the investment
vehicle is established. Beneficiary designations should be reviewed periodically.
5. Employees are responsible for all distributions and any other transactions with their service provider. All rights under the investment(s) are
enforceable solely by Employee, Employee beneficiary or Employee’s authorized representative. Employee must work directly with the
service provider to transfer contract(s) or custodial account(s) to another service provider, begin distributions, make loans, or otherwise
access Plan assets.
6. Employees are responsible for determining that salary reductions do not exceed the allowable contribution limits under Applicable Law.
References herein to elective deferral limits are based on the 2015 IRS limits.
Part
IV:
Signatures
I certify that I have read this complete Agreement and that my salary reductions do not exceed contribution limits as determined by Applicable
Law. I also certify that I am eligible for the catch up election(s), if selected, under Part 2 above. I understand my responsibilities as an
Employee under the Plan, and I request Employer to take the action specified in this Agreement. I understand that all rights under the
investment(s) established by me under the Plan are enforceable solely by me, my beneficiary or my authorized representative.
Employee Signature Date: (mm/dd/yyyy)
I hereby acknowledge my responsibility to comply with Employer’s written directives regarding solicitation of Employees. I also acknowledge
my responsibility to assist the Employee in determining the maximum contribution limits. (Please Print)
Agent/Representative Name Date: (mm/dd/yyyy)
Address Phone
Employer hereby agrees to this Salary Reduction Agreement and further agrees to identify both t contributions at the time of remittance to the
selected Investment or Insurance Provider(s).
Received by: Date: (mm/dd/yyyy)
Processed by: Date: (mm/dd/yyyy)
Title
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Part III: Agreement and Important Information
