_______________________
Supplemental Retirement Annuity (SRA)
457(b) Deferred Compensation Plan
Voluntary Salary Deferral Agreement
University System of Maryland (USM)
I, ______________________________________, SSN ____________________, elect to
(First Name Middle Initial Last Name)
(CHOOSE ONE ACTION): Enroll New____ Change participation____ Cancel participation____
in the 457(b) Deferred Compensation Plan offered by the following company:
FIDELITY INVESTMENTS __________ TIAA-CREF _________
MD SUPPLEMENTAL RETIREMENT PLANS (MSRP) – Nationwide_________
To this 457(b) Deferred Compensation Plan, I elect to contribute $___________, bi-weekly. This
contribution amount will continue in subsequent calendar years if a new salary reduction agreement is
not received. Please note that if this contribution is not being taken over 26 paychecks, it will be
necessary for the employee to make an adjustment the following calendar year in order to avoid over-
withholding. I have also attached a completed Payroll Deduction Authorization Card as required to
process this transaction.
This salary reduction will begin with the paycheck issued on __________, 20 or on such later date as
may be appropriate due to required payroll procedures.
If I am contributing to retirement plans through another employer, those contributions may affect the
amount that I can contribute to a SRA. I understand that I should consult with the vendor on Internal
Revenue Code (IRC) regulations contribution limitations.
In signing this form I am also giving the University my authority to release employment information to the
company selected above for the purposes of monitoring compliance of my account(s) with IRC
regulations.
This agreement shall be legally binding and irrevocable as to each of the parties involved. However,
either party may terminate this agreement as of the end of any month, so that it does not apply to
subsequently earned salary, by giving at least 30 days written notice of termination
The amount deferred hereunder will produce a total deferral that does not exceed the applicable
limitations of the Internal Revenue Code.
Signature: ________________________________ Date: ___________________________
USM Institution ____________________________ Office Phone: _____________________
USM Benefits Coordinator: _______________________ Date: _____________________
(Institution Representative)
USM Form RV – 457(b) SRA – Voluntary Salary Deferred Agreement Form - Revised 01/01/08
