Instructions - 403-200 (03/2015)
8523 S Redwood Rd, West Jordan, UT 84088 ● (800) 274 0503 ext 5 ● Fax (800) 597-8206 www.NBSbenefits.com
403(b) and/or 457(b) Salary Reduction Agreement
Participant Instructions
The Salary Reduction Agreement (SRA) is used to establish, change, or cancel salary reductions withheld from your paycheck and contributed to the
403(b) and/or 457(b) Plan on your behalf. The SRA is also used to change the investment providers that receive your contributions. Upon completion,
fax or mail a copy of the form to National Benefit Services, LLC. Please note that this form is not valid unless all applicable sections are completed and
you have signed the form. If you have questions regarding this form, please call 1-800-274-0503 ext 5.
Upon completion, fax (1-800-597-8206), email, or mail a copy of the form to National Benefit Services, LLC.
Please submit the original to your payroll office.
Important Information
The Employee agrees to indemnify and hold the Employer and National Benefit Services, LLC (NBS) harmless against any and all actions, claims, and
demands that may arise from the purchase of annuities or custodial accounts in this 403(b) and/or 457(b) Plan. The Employee acknowledges that
neither the Employer nor NBS have made representation to the Employee regarding the advisability, appropriateness, or tax consequences of the
purchase of the annuity and/or custodial accounts. The Employee agrees that neither the Employer nor NBS shall have any liability for any and all
losses suffered by the Employee with regard to his/her selection of the annuity and/or custodial account; its terms; the selection of the insurance
company or regulated investment company; the solvency of, operation of, or benefits provided by said insurance company or regulated investment
company; or his/her selection and purchase of shares of regulated investment companies.
The Employer reserves the right to alter terms of this Agreement as required to facilitate program compliance with state and federal law.
The Employer does not choose the annuity contract or custodial account in which the Employee's contributions are invested.
The Employee is responsible for setting up and signing the legal documents to establish the annuity contract or custodial account.
In order for the Employee to receive the expected tax results, the annuity contract or custodial account established must meet the requirements of
Section 403(b) and/or 457(b) of the Internal Revenue Code. It is solely the Employee’s responsibility to establish the proper type of contract or account
for this purpose.
The Employee is responsible for naming a death beneficiary under the annuity contract or custodial account. This is normally done at the time the
contract or account is established, although the designation should be reviewed from time to time.
The Employee is responsible for investment decisions, distributions and any other transactions with the insurance company or investment company
and shall have total responsibility for all distributions and any resulting tax consequences. All rights under the contract or account are enforceable
solely by the Employee, the Employee’s beneficiary, or the Employee’s authorized representative.
The insurance or investment company may be required to receive approval from the Employer or National Benefit Services, LLC, prior to executing
certain transactions including loans, hardships, distributions, or transfers (as permitted by the Plan).
The Employee understands that information contained in this Agreement and other non-public information may be shared with the Employer's
designated third-party administrator in conjunction with the operation of the 403(b) and/or 457(b) Plan.
Retain a copy of this form for your records.
Form - 403-200 (03/2015)
8523 S Redwood Rd, West Jordan, UT 84088 ● (800) 274 0503 ext 5 ● Fax (800) 597-8206 www.NBSbenefits.com
403(b) and/or 457(b)
Salary Reduction Agreement
1 Personal Information
Employer Name
Participant Mailing Address, City, State, Zip Code
Phone Number
Date of Birth
Date of Hire
Participant Email Address
Social Security Number (required)
2 Salary Reduction
The Salary Reduction Agreement (SRA) is to be used to establish, change, or cancel salary reduction withheld from your paycheck
and contributed to the 403(b) and/or 457(b) plan on your behalf. To change, begin, or cancel contributions, enter your desired
amount(s) and investment provider(s). This SRA will cancel and replace any previously submitted SRA. You must list all new
and existing deductions on this SRA form or they will be cancelled. The salary reductions identified in the space below will be the
only deductions performed starting on the Effective Date.
Investment Provider Name*
Monthly Dollar
or Percentage
Amount
Type of Deferrals
Requested Action
Effective
Date
Pre-Tax
403(b)
Roth
403(b)
Pre-Tax
457(b)
Roth
457(b)
Other
$ or %
New Existing
Change Cancel
$ or %
New Existing
Change Cancel
$ or %
New Existing
Change Cancel
Total Monthly Contributions
____________
*Please Note: Certain investment providers may not pay the administration fee. If you select an investment provider that does not
pay the administration fee, the fee will be deducted and paid from your salary reduction amount. Please refer to the approved
vendor list at www.nbsbenefits.com/403b for a current listing of providers that have agreed to pay the fee.
3 Financial Advisor/Agent Information
Financial Advisor/Agent Name
Financial Advisor/Agent Phone Number
Financial Advisor/Agent Email Address
Financial Advisor/Agent Fax Number
4 Employee Approval
I understand and agree to the following:
1. This Salary Reduction Agreement (Agreement) is an agreement between me and my employer that I have entered into voluntarily.
2. This Agreement supersedes and replaces all prior Salary Reduction Agreements.
3. The Agreement is legally binding and irrevocable with respect to amounts paid or available while this agreement is in effect.
4. The Agreement may be terminated or modified at any time for amounts not yet paid or available.
5. Nothing herein shall affect the terms of my employment with the Employer.
6. This Agreement shall automatically terminate if my employment is terminated.
I authorize the automatic cancellation of this Salary Reduction Agreement in the event of any of the following: (1) if either my employer or National
Benefit Services, LLC (my employer’s third-party administrator) believe additional contributions will cause me to exceed limits under Code Section
415 or 402(g), (2) if I take a hardship distribution, if available, or (3) if I take an unforeseeable emergency distribution, if available.
I have read and understand the information contained on page 1 of this Agreement. I understand that by making this application the release of my
confidential information to third parties may occur as necessary to administer the Plan in accordance with the Internal Revenue Code.
Employee Signature
Date
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