WEST VIRGINIA NORTHERN COMMUNITY COLLEGE
COMPENSATION DEFERRAL ELECTION UNDER SECTION 403(b) PLAN
This election is to contribute a portion of your compensation to the Section 403(b) Plan sponsored by West Virginia Northern Community
College (“WVNCC”). The amount that you choose to defer pursuant to Parts I and II below shall not exceed the applicable limitations of
Internal Revenue Code. Amounts contributed to the Section 403(b) Plan will be invested among the investment options approved from time to
time by the West Virginia Higher Education Policy Commission ("the Commission") and selected by you in a separate investment election
form.
Subject to any advance notice period to process this election for payroll purposes, this election shall become effective on the later of the
following: (i) the first day of the month following the date of your signature below and return to the Human Resource Office; or (ii) on the first
of the month so indicated on the effective date section of this form following the return of this election to the Human Resource Office. This
election replaces any previously submitted election form for this plan, and shall remain in effect unless revoked or modified in writing as
permitted by the terms of the Section 403(b) Plan and in accordance with such form(s) as the Commission may from time to time provide.
If you have any questions about the amount that can be deferred under Parts I or II below or any of the categories in these parts, please contact
the Human Resource Director. Please be advised that any election you make below applies only to salary deferrals from the 403(b) Plan
sponsored by the Commission. If you participate in another 403(b) plan or another qualified retirement plan, you should consult your tax
advisor regarding the overall limits that apply in your situation.
PART I - GENERAL COMPENSATION DEFERRAL ELECTION [Select only one]
You may select an amount to be deducted and contributed per payroll based on a fixed dollar amount or a percentage of your compensation for
the pay period. Alternatively, you may select an amount to be deducted and contributed each payroll period based on the maximum annual
amount permitted by federal law, without taking into consideration any permissible catch-up contributions permitted by federal law.
The amount of the compensation reduction shall be as follows:
% This will be percentage of the gross salary on the effective date of this request.
Any changes to the gross salary will not be reflected.
Note: If you select the maximum amount allowed by law, the amount deferred will be based solely on your participation in the Section 403(b) Plan sponsored by the Commission,
and you will be required to notify your Human Resource Office each year of any desired changes. For instance, if the maximum contribution amount is increased by law, this
election will not automatically authorize an increase in your deferral election. Rather, contributions will remain at the maximum amount permitted at the effective date of this
election unless a new election is completed.
PART II - CATCH-UP CONTRIBUTION ELECTION [Select only one]
The compensation deferral amount selected under Part I above shall be increased by the additional deferral amount selected below.
Note: Certain federal law limitations apply in determining whether you are eligible to select an option under Part II. Please consult with the Human Resource Director if you
have questions. In addition, if you select the maximum amount allowed by law, the amount deferred will be based solely on your participation in the Section 403(b) Plan
sponsored by Commission, and you will be required to notify the Human Resource Office each year of any desired changes. For instance, if the maximum contribution amount is
increased by law, this election will not automatically authorize an increase in your deferral election. Rather, contributions will remain at the maximum amount permitted at the
effective date of this election unless a new election is completed.
Annual Dollar Amount (Amount per pay period) $
Percentage Amount of Gross Salary
Maximum amount allowed by law (without catch-up contributions)
Additional annual amount for individuals age 50 or over (Amount per pay period) $
Maximum amount permitted by law for indiviudals age 50 or over.
Date of Birth:Social Security Number:Employee's Name:
PART III - VENDOR SELECTION [Select only one]
After a review of the materials provided by the vendors, I elect to participate in the 403(b) program provided by:
Note: A separate enrollment and investment allocation form for the selected vendor must be completed and forwarded to the Human Resource Office prior to any payroll deduction.
Human Resource/Payroll Use Only
Payroll Deferral entered into EPICS by: ___________________________________________________ Effective Date: ______________________________________________
PART IV - SIGNATURE VERIFICATION & EFFECTIVE DATE
Upon completion and signature of this election form, please return it to the Human Resource Office. The submission of this deferral election
form will replace any prior elections made by the participant for this plan.
Employee Signature: _____________________________________Date:_________________Effective date of change: ________________
The effective date shall be the first day of the month following the submission of this form or at the beginning of the month indicated above.
TIAA-CREF (339)GreatWest/Educator$Money (377)
