Salary Reduction Agreement
• Before completing this form, check with your employer to see if there is a specific salary reduction form
that you should use. If there is not, use this form to make or change your instructions to have your
employer deduct money from your paycheck for your retirement account investment.
• Provide your completed form to your employer.
1
2
Please print clearly in CAPITAL letters using black ink and sign on Page 2.
If you have questions about this form, please call a Business Retirement Specialist at 1-800-345-3533.
Provide Salary Reduction Information
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Social Security
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Tax ID
Date
Plan ID
Phone
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Plan year-end
Amount
Year Percentage
Brokerage account number
Signature
Account number
$
, , .
$
%
Today’s date (month-day-year)
Indicate type of account: 401(k) 403(b) 457(b) SARSEP-IRA SIMPLE-IRA
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Social Security
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Tax ID
Date
Plan ID
Phone
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Plan year-end
Amount
Year Percentage
Brokerage account number
Signature
Account number
$
, , .
$
%
Employee’s name
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Social Security
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Tax ID
Date
Plan ID
Phone
-
Plan year-end
Amount
Year Percentage
Brokerage account number
City State ZIP +4
Signature
Account number
$
, , .
$
%
Employee’s U.S. Social Security number
The employee and employer agree as follows:
Frequency: weekly biweekly semimonthly monthly
I request that my salary be reduced by
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Social Security
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Tax ID
Date
Plan ID
Phone
-
Plan year-end
Amount
Year Percentage
Brokerage account number
City State ZIP +4
Signature
Account number
$
, , .
$
%
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Social Security
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-
Tax ID
Date
Plan ID
Phone
-
Plan year-end
Amount
Year Percentage
Brokerage account number
City State ZIP +4
Signature
Account number
$
, , .
$
%
Amount OR Percentage
Please indicate if the amount above is for one of the following:* Roth 401(k) Roth 403(b)
The amount of this reduction will be paid to American Century Investments for deposit to my retirement
account selected above. This amount will be invested in accordance with the plan and as designated by me.
The amount elected is subject to any applicable limitations under the Internal Revenue Code.
*Check with your employer to find out if Roth 401(k) and Roth 403(b) are available through your plan.
Indicate the Date Salary Reductions Begin
Fill in the date you want your salary reduction to begin. The date entered here must be after the date
entered in Step 1.
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Social Security
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Tax ID
Date
Plan ID
Phone
-
Plan year-end
Amount
Year Percentage
Brokerage account number
Signature
Account number
$
, , .
$
%
Start date (month-day-year)
I understand that my salary reduction will start as soon as permitted under the retirement plan indicated in
Step 1 and as soon as administratively feasible.
