403(b) Retirement Savings Plan

403(b) Retirement Savings Plan
403(b) Retirement
Savings Plan
402 South Kentucky Ave., Suite 500, Lakeland, FL 33801
866.873.4240 ♦ Fax 863.688.4200 ♦ www.midamerica.biz
Questions? Call our Service Center at 1-866-873-4240
Salary Reduction Agreement
Use this form to set up or change contributions to your 403(b) Account. Please type or print your information and fax to (863) 688-4466.
Employer Name:
Daytime Phone #:
Evening Phone #:
Email Address:
Social Security #:
Date of Birth:
Date of Hire:
Number of Payrolls per Year:
Contribution Specifications
Complete this section to set up or change contributions to your 403(b) Account. Please note that the contribution amount may not
exceed the maximum allowable limits as determined by the Internal Revenue Code. Review your Plan Highlights for the availability of
Age 50 or 15 Years of Service Catch-up Contributions. Click to view the Maximum Amount Contributable (MAC) limits for the current
tax year.
Start new payroll deductions (Account must be established under your current employer’s plan prior to submitting SRA,
fill in Account Number below).
Increase existing payroll deductions.
Decrease existing payroll deductions.
One-time payroll deduction then stop deductions.
One-time payroll deduction then revert to existing deductions.
Change investment providers. Stop contribution to
and start contributions to
Please stop my contributions to
Make changes effective with payroll date
You are responsible for establishing any annuity contract or custodial account with the Investment Provider(s) indicated below prior to
submitting your Salary Reduction Agreement. Please provide your account # to avoid delay in processing your changes.
Investment Provider(s)
Account #
Annual Salary Reduction
Salary Reduction Per Pay Period
Total deduction each pay period $
After the initial SRA is submitted and approved by MidAmerica, subsequent changes can be made online at: https://fe2.midamerica.biz/login.aspx.
Approval Signature
403(b) deferrals can start no earlier than the first pay period following the date this agreement is signed.
This Salary Reduction Agreement is irrevocable with respect to amounts earned while it is in effect and applies only to amounts
earned after the agreement becomes effective.
The Employee agrees to pay the administrative fees deducted from contributions on a pro rata basis.
This Salary Reduction Agreement will continue until amended or terminated. This agreement shall automatically terminate with
severance from employment.
The Employee agrees that the Employer shall have no liability whatsoever for any loss suffered by the Employee with regard to
his/her selection of an investment provider, or the solvency of the operation of, or benefits provided by, said investment provider.
Signature of Employee
Date (Please Note: Above date must be within last 90 days to be valid)
Rev. 01.01.2015
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