Salary Reduction Agreement
403(b)(9) Retirement Plan
Return to your employer when completed.
PARTICIPANT INFORMATION
Participant name: __________________________________________________________________________ Social Security number (last four digits): ___________________
Birth date: ______/ ______/ ______ Marital status:
Married Single Daytime telephone: ( ________ ) ___________________________________
Home address: ____________________________________________________________________________________________________________________________
City: _______________________________________________________________________________ State: __________ ZIP Code: ____________________________
PARTICIPANT ELECTION
This agreement is made between the participant and the employer. Any change to this agreement must be filed in accordance with procedures
established by the employer.
I, the undersigned participant, hereby elect to:
Tax-sheltered contributions
Defer from my salary on a tax-sheltered basis ____________ (whole percentage or dollar amount) of compensation (not to exceed applicable
legal limitations).
Cease my tax-sheltered deferral contributions.
Roth elective deferrals (May not be available for all plans. Please contact your employer to verify eligibility.)
Defer from my salary as a Roth elective deferral __________ (whole percentage or dollar amount) of compensation (not to exceed applicable
legal limitations).
Cease my Roth elective deferral contributions.
Tax-paid contributions
Deduct from my salary on an after-tax basis __________ (whole percentage or dollar amount) of compensation (not to exceed applicable legal
limitations). I understand that the amount of such deduction, pursuant to this election, will be withheld from my paychecks and paid by my
employer into my account in the plan.
Cease my after-tax contributions.
EFFECTIVE DATE
Make the effective date of this agreement the first day of the next pay period.
Make the effective date of this agreement as of : ______/ ______/ ______ . (Date must be prospective.)
PARTICIPANT SIGNATURE
I understand the amount of such reduction, pursuant to this election, will be withheld from my paychecks and paid by my employer into my account
in the plan. I understand (1) my election regarding tax-sheltered or Roth elective deferrals is irrevocable once the employer withholds the deferrals
from my paycheck; and (2) and any change of election regarding tax-sheltered or Roth elective deferrals is effective only for deferrals from paychecks I
receive after the plan administrator accepts my change of election. I further understand that written notice must be given before the effective date of
any modification. This election will remain in effect until I revoke it in writing or until I complete a new Salary Reduction Agreement.
Participant signature: _____________________________________________________________________________________ Date: ______/ ______/ ______
EMPLOYER SIGNATURE
Employer signature: ______________________________________________________________________________________ Date: ______/ ______/ ______
Employer name: ____________________________________________________________________ Plan name: ______________________________________
DO NOT SEND TO GUIDESTONE
You and an appropriate business officer of your employer should sign the Salary Reduction Agreement. Keep a copy of the agreement with
your tax records. Your employer should keep the original agreement. DO NOT send the agreement to GuideStone Financial Resources or the
Internal Revenue Service.
© 2012 GuideStone Financial Resources 19190 1/12 2289
*2289*
Reset form
Information about the Salary Reduction Agreement
Use of form
You may use this form to: (1) make an initial salary reduction agreement, (2) change the amount of your existing salary reduction contributions,
or (3) stop your salary reduction contributions.
General information
Your Salary Reduction Agreement is a written, legally binding agreement between you and your employer. It is an agreement whereby you direct
your employer to reduce compensation not yet currently available (referred to as “your salary”) by a specific percentage or amount. Your employer
then sends this amount to the plan or plans specified in the agreement as a tax-sheltered contribution or an irrevocable Roth after-tax elective
deferral contribution to your account in accordance with Section 403(b) of the Internal Revenue Code (“Code”). Your employer may also make con-
tributions to the plan in addition to your contributions.
You may change the percentage or amount of your salary reduction agreement at any time for compensation not yet currently available. Your
current Salary Reduction Agreement will continue until you sign a new salary reduction agreement.
For most people, it is wise to designate contributions as a percentage of salary rather than a fixed dollar amount. If your salary increases during
the year, your contributions will increase automatically without having to make a new agreement.
You may cancel your Salary Reduction Agreement at any time with respect to compensation not yet currently available.
Limitations on contributions
The Internal Revenue Code limits the amount of contributions that you may make each calendar year. Failure to comply with the Code Section 402(g)
limit on tax-sheltered contributions and/or Roth elective deferrals may disqualify the tax-favored status of your account. Tax-sheltered contributions
or Roth elective deferrals that meet the requirements of Code Section 414(v) are not counted for purposes of determining the Code Section 402(g)
limit. Once tax-sheltered contributions and/or Roth elective deferrals in a calendar year reach the Code Section 402(g) limit, subsequent tax-sheltered
contributions and/or Roth elective deferrals will be treated as contributions under Code Section 414(v), to the extent the requirements for that sec-
tion are met. GuideStone Financial Resources can assist you in determining your annual maximum contribution limits. This is particularly important if
you coordinate your contributions with your employer’s fiscal budget year or participate in more than one plan.
For more details regarding contribution limits, please contact GuideStone at 1-888-98-GUIDE (1-888-984-8433).
Execution of the agreement
You and an appropriate business officer of your employer should sign the Salary Reduction Agreement. Keep a copy of the agreement with
your tax records. Your employer should keep the original agreement. DO NOT send the agreement to GuideStone Financial Resources or the
Internal Revenue Service.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome