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
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