alary Reduction Agreement (403b)

alary Reduction Agreement (403b)
Prince George’s County Public Schools, Maryland
Salary Reduction Agreement for 403(b) Annuity Contract or 403(b)(7) Custodial Account
Please Print or Type Legibly
Employees must establish an account with an authorized 403(b) investment provider PRIOR to completing this form.
1
Employee Name
2
Employee Email Address
Work Location
Employee I.D. Number
Mailing Address
Number of Payrolls Per Year:
22*
24*
26
Reductions are not withheld for 10/11 month employees during the summer.
3
4
Original Agreement or
Reduction Amount
Amendment to a Previous Agreement
If effective payroll date is blank, changes will take effect the next
processing period after date of receipt of this form by TSACG.
List all companies and salary reductions requested whether new or existing.
IMPORTANT: Read instructions on page 2 of this form.
Company Name
Payroll Slot Number
The total amount of contributions to all providers
Effective Payroll Date
Salary Reduction Amount
,
.
M M D D Y Y
,
.
M M D D Y Y
,
.
M M D D Y Y
,
.
for each pay period.
NOTICE: Any 403(b) reductions not listed will be automatically terminated.
This Agreement shall be legally binding and irrevocable with respect to amounts earned while the Agreement is in effect, and any termination of this Agreement
shall be effective only with respect to amounts not yet earned at the time of said termination. This reduction may not exceed the employee’s statutory limit per
Section 403(b), Section 402(g) or Section 415 of the Internal Revenue Code, that limits the total allowable salary reduction to all Companies to which salary
reduction contributions can be made. This Agreement must also be accompanied by a Product Disclosure form signed by the representative and employee for all
original salary reductions established by this Agreement or any changes in investment products relating to this Agreement.
I hereby authorize my Employer to reduce or suspend any contributions established by this agreement if in its opinion the total annual contributions would exceed
my Maximum Allowable Contribution in any calendar year.
The Employee is responsible for the accuracy of the excludable amounts stated in this Agreement. Any overstatement of the amounts excludable as a salary
reduction in this agreement, or any other violation of the requirement of Section 403(b) could result in additional taxes, interests, and penalties to the Employee.
It is the intent of the parties that the non-forfeitable retirement deferred annuity or custodial contract pursuant to this Agreement shall qualify for the federal
income tax benefits provided for in Section 403(b) of the Internal Revenue Code. Any change to this Agreement must be in writing to the Employer and
becomes effective upon the execution of this Agreement by Employee and Employer.
This Agreement may be terminated by either the Employer or Employee upon notice to the Employer or Employee as applicable. This Agreement is processed by
TSA Consulting Group, Inc., as the Administrator by Contract for Prince George’s County Public Schools’ 403(b)/403(b)(7) plan administrator services provider.
5
7
6
___________________________________________
AGENT/REPRESENTATIVE (IF APPLICABLE) — PRINT NAME
__________________________________________
EMPLOYEE TELEPHONE NUMBER
I agree with the terms above:
___________________________________________
AGENT/REP PHONE
__________________________________________
EMPLOYEE SIGNATURE
Date of this Agreement_____________________ , 20_______
___________________________________________
EMPLOYER ACCEPTANCE OF AGREEMENT/CONTRACT
SRA is not valid if “Effective Payroll Date” in Section 4 is more than 90
days from the “Date of this Agreement” in Section 7.
Mail or fax your SRA form to:
TSA Administration Services
Attn: SRA Processing Dept.
P.O. Box 4037
Fort Walton Beach, FL 32549
Fax:
1-866-908-7582
Phone: 1-888-796-3786 Ext.526
Copyright © 2015 TSA Consulting Group, Inc./TSACG
Page 2—Instructions
Employee Instructions:
1.
Complete the Employee sections regarding “Name,” “Email Address,” “Mailing Address” and “Work Location.” Select the number of payrolls* that you, the
employee, receive during a calendar year. *Deductions not withheld for 10 month employees during summer.
2.
Enter your “I.D. Number” and/or “Social Security Number” in the boxes provided.
3.
Mark the box that corresponds with the type of SRA your are submitting: “Original Agreement” or “Amendment to a Previous Agreement.”
4.
(a) Enter the info for ALL your new and/or existing accounts (you may have only one account or multiple accounts).
NOTICE: Any SRA accounts not listed will be automatically terminated.
(b) In addition to entering the company name, the employee and/or agent MUST fill in the correct corresponding Assigned Payroll Slot Code on the SRA
(list available with this SRA or online at https://www.tsacg.com/employee_site/districts/maryland/prince_georges.htm).
(c) Enter the salary reduction amount (dollar amount) you wish to be withheld from your payroll.
(d) Enter the month or payroll date that you wish your elections (new account or amendment) to be effective.
(i) If effective payroll date is blank, changes will take effect the next processing period after date of receipt of this form by TSACG.
(e) If this SRA is bei ng submitted to terminate a current salary reduction, please list the company name to be terminated and indicate “Terminate
Reduction” in the space provided (check box).
(f) Total the dollar amount for all contributions, and enter the total in the box provided.
5.
Complete this section for unused sick leave payout only.
6.
Provide agent name and telephone number, if applicable.
7.
Sign and date the agreement. Please provide a telephone number where you can be reached during business hours.
8.
Mail the completed original signed agreement to TSA Administration Services, Attn: SRA Processing Dept., P.O. Box 4037, Fort Walton Beach, FL 32549
or fax the completed form to 1-866-908-7582.
The employer, Prince George’s County Public Schools, will apply and remit the salary reduction documented on page 1 of this SRA form to TSA Consulting
Group, Inc. The administrator is providing remittance and administration services for voluntary retirement plans for PGCPS.
PRIVACY - The administrator shall take all reasonable precautions to prevent disclosure or use of the information for a purpose unrelated to administration of the
plan.
The administrator shall disclose information described only:
(a) in response to a court order;
(b) for an examination conducted by the commissioner of insurance;
(c) for an IRS audit or investigation;
(d) to or at the request of the insurer or plan sponsor; or
(e) with the written consent of the identified individual or his or her legal representative.
Salary Reduction Agreement (SRA) Processing—Upcoming Deadlines for 2015 and 2016
015/2016 SRA Submittal
DEADLINE Date
2015/2016 Effective
Payroll Date
2007
SRA
2015/2016 SRA Submittal
DEADLINE Date
2015/2016 Effective
Payroll Date
June 19, 2015
July 2, 2015
January 1, 2016
January 15, 2016
July 3, 2015
July 17, 2015
January 15, 2016
January 29, 2016
July 17, 2015
July 31, 2015
January 29, 2016
February 12, 2016
July 31, 2015
August 14, 2015
February 12, 2016
February 26, 2016
August 14, 2015
August 28, 2015
February 26, 2016
March 11, 2016
August 28, 2015
September 11, 2015
March 11, 2016
March 25, 2016
September 11, 2015
September 25, 2015
March25, 2016
April 8, 2016
September 25, 2015
October 9, 2015
April 8, 2016
April 22, 2016
April 22, 2016
May 6, 2016
October 9, 2015
October 23, 2015
May 6, 2016
May 20, 2016
October 23, 2015
November 6, 2015
May 20, 2016
June 3, 2016
November 6, 2015
November 20, 2015
June 3, 2016
June 17, 2016
November 20, 2015
December 4, 2015
December 4, 2015
December 18, 2015
December 18, 2015
January 1, 2016
Submittal
DEADLINE Date
2007 Effective Payroll Date
Prince George’s County Public Schools, Maryland
Salary Reduction Agreement for 403(b) Annuity Contract or 403(b)(7) Custodial Account
Prince Georges County Public Schools
Vendor Payroll Slot Codes
403(b) Investment Providers
ASPire Financial Services
American Century Investments
AXA Equitable Life Insurance Company
Fidelity Investment
First Investors Corporation
Franklin Templeton Funds
Great American Financial Resources
Horace Mann Insurance Company
Life Insurance Company of the Southwest
Lincoln Financial Group
Lincoln Investment Planning
MetLife Resources
Midland National
Oppenheimer Funds
PFS Investments (Primerica)
PlanMemeber Services
Reliastar Life Insurance Company
Security Benefit Group
TIAA-CREF
VALIC
Waddell & Reed, Inc.
Payroll Slot Number
B7104
B7103
B1107
B7112
B7114
B7115
B1116
B1117
B1120
B1122
B7121
B7126
B1129
B7134
B7141
B7140
B1145
B1146
B1158
B1165
B7168
Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Download PDF

advertisement