Revised 6/2020 \\zeus\HR\common\Benefits\FORMS\Retirement Plan Forms\Investment Election Form fillable 6-2020 access.docx
UNION COLLEGE RETIREMENT PLAN
INVESTMENT ELECTION, PARTICIPATION, and DOCUMENT RECEIPT FORM
Agreement for Salary Reduction under Section 403(b)
Name:__________________________________________________________________________________________ (Please Print)
I. Receipt of Universal Availability Notice, Summary Plan Description, and Summary of Material Modifications
Completion of this section signifies that I have received a copy of Union College’s 403(b) Retirement Plan Universal Availability Notice,
Summary Plan Description, and Summary of Material Modifications.
II. Union’s 11% Defined Contribution (This section applies to Union’s contribution on your behalf)
Under the rules and regulations of the Union College Retirement Plan, if eligible, I elect to have the College's contribution (11% of my
annual salary/wage) allocated as follows (total percent indicated must add up to 11):
________ % TIAA ________% FIDELITY
III. Employee’s Pre-Tax 403(b) Contribution (This section applies to your voluntary pre-tax payroll deducted contribution)
If this section is completed, I elect to have my salary/pay reduced by __________% or by $_______ per pay/ annually (check one)
before taxes and allocated as follows:
________ TIAA-GSRA ________ FIDELITY { ________ TIAA ________ TIAA-SRA}
{ For existing Union College contracts only }
IV. Employee’s Roth (After-Tax 403(b)) Contribution (This section applies to your voluntary after-tax payroll deducted contribution to the Roth
403(b) account)
If this section is completed, I elect to have my salary/pay reduced by __________% or by $_______ per pay/ annually (check one)
after taxes and allocated as follows:
________ TIAA ________ FIDELITY
V. Non-Participation Election
Completion of this section signifies that I am electing not to make a voluntary contribution to the Union College 403(b) Retirement Plan
at this time. This election only relates to my voluntary contributions and does not mean that I am declining participation in the
employer-contributed portion of the plan. Should I decide to begin voluntary contributions, I understand that I must complete a new
Investment Election Form.
Amounts indicated will produce a total College contribution that does not exceed the maximum amount permitted by law. In addition, employee
contributions will not exceed the statutory limitation under IRC Section 403(b) with this plan alone or in aggregate with plans through other
employers. I understand that I am responsible for determining that the amount of my salary contributed does not exceed the limits on
contributions. I also understand that my employer will provide to me, upon my request, any available information from the employer’s records
that is necessary to enable me to make these determinations. For employees age 50 and over or employees with at least 15 years of service, the
employee contribution amount may include an additional catch up contribution to the maximum amount permitted by law. This agreement shall
be legally binding and irrevocable for both the institution and the employee while employment continues. However, the employee may
terminate or otherwise modify this agreement at anytime by completing and submitting a new Retirement Plan Investment Election,
Participation and Document Receipt Form at least 30 days prior to the desired effective date of a change.
_________________________________ _____________________
Employee Signature ID # Date
______________________________________________________________________________________________________________________________________________
Human Resources Only: Change Effective: / / .
No. ST FQ Amt Additive
Contribution: 1020 TIAA A A _________ _________
1021 Fidelity A A _________ _________
Deduction: Salary Reduction 2020 TIAA A A _________ _________
2021 Fidelity A A _________ _________
SRA Reduction 2025 TIAA A A _________ _________
GSRA Reduction 2026 TIAA A A _________ _________
ROTH Reduction 2029 TIAA A A _________ _________
2023 Fidelity A A _________ _________
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* If you are electronically submitting this form, put your electronic signature by marking the box and typing your name above.
