Page 1 of 2 - 403-200 (11/2012)
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 to be 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.
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 whatsoever 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 whatsoever 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 taxation 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 or 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.
