FACULTY/STAFF SALARY REDUCTION AGREEMENT
FOR 403b SUPPLEMENTAL RETIREMENT ACCOUNT
Name ________________________________ Social Security Number _________________
Under Age 50 Age 50 and Over
I. When would you like the contribution/change to be effective?
Effective the next available pay period OR Effective __________________________
(insert date)
II. How much is the requested salary reduction?
Reduce pay by (select only one):
Flat dollar amount per pay (NO ANNUAL AMOUNTS PLEASE)
If a flat dollar amount is elected, the deduction will be taken every time you receive a
paycheck (For faculty this includes summer pay)
Percent of all compensated earnings (For faculty this includes summer pay.)
*If you wish to contribute more than the maximum allowed as indicated on the reverse side of this form, you
must attach a copy of your Maximum Exclusion Allowance (MEA) Calculation with this form. MEA
calculations can be obtained through your investment vendor.
Maximum contribution limits are listed on the reverse of this form.
Elections will remain effective until a new salary reduction form is submitted to Human Resources.
Maximized contributions will not automatically increase each year.
Once maximum contribution amounts are met, deductions will cease for the remainder of the calendar
year. Beginning January of the following year, deductions will begin again with the same amounts
previously elected unless a new salary reduction form has been completed.
III. Where would you like the contributions sent? If you select more than one, please indicate
amount/percent to be sent to each vendor.
TIAA-CREF Fidelity
American Funds __________ New England (Existing Members Only)
IV. Please select one:
Established 403b Supplemental Retirement Account
403b Supplemental Retirement Account Application(s) attached
_____ 403b Supplemental Retirement Account Application Completed with Financial Advisor
Please complete reverse side of this form.
I HEREBY, for myself, my heirs, executors and personal representatives hold harmless and indemnify the University, its
officers, faculty and staff members, from every claim and demand for penalties, taxes, withholding and/or interest which
may be made by reason of challenge to the tax-qualified status on any annuities or mutual funds purchased by the
University for me or by reason of challenge to the maximum exclusion allowance. I have read the terms of this
agreement on the reverse side and understand and accept these terms. I authorize the amount stated in Section II to be
deducted and transmitted as I have indicated in Section III.
_________________________________________________ _____________________
Faculty/Staff Member Signature Date
_________________________________________________ _____________________
Human Resources Representative Signature Date
MAXIMUM CONTRIBUTION LIMITS
Tax Year Under Age 50 Age 50 and over
2002 $11,000 $12,000
2003 $12,000 $14,000
2004 $13,000 $16,000
2005 $14,000 $18,000
2006 $15,000 $20,000
2007 $15,500 $20,500
This agreement is legally binding and irrevocable for both the University and the Participant with respect to the amounts
earned while the agreement is in effect. However, either party may terminate the agreement given at least two weeks
written notice. The agreement will not apply to salary earned after the agreement is terminated. This agreement
replaces any previous agreements.
The purpose of the University in executing this amendment is to provide the Participant with an opportunity to benefit
from the provisions of section 403b of the Internal Revenue Code of 1954 (as amended) of the United States.
The Participant understands that there are choices available and is responsible for requesting, reading and
understanding the prospectus prior to the designation of retirement fund options. The University, its officers and faculty
and staff are not responsible for any information or advice provided by the respective companies, or any loss as a result
of the participant’s selection.
The University does not warrant any particular tax consequences to the Participant.
______ HRS ______SQL $___________