By signing this Agreement, Employee agrees to modify his/her salary as indicated and Employer agrees to contribute this
amount on Employee’s behalf into the 403(b) annuity(s) or custodial account(s) selected by Employee and authorized by
Employer under the Employer’s 403(b) Plan. Employer agrees to properly identify pre-tax 403(b) contributions and after-tax
Roth contributions for proper allocation to segregated accounts by the investment providers. It is intended that the
requirements of all applicable state and federal tax rules and regulations (Applicable Law) will be met.
Employee understands and agrees that this Agreement:
- Is legally binding and irrevocable with respect to amounts paid or available while it is in effect and is effective only for amounts not yet earned or made available.
- May be terminated at any time for amounts not yet paid or available, and that a termination request is permanent and remains in effect until a new salary reduction agreement is submitted.
- Supersedes all prior 403(b) salary reduction/amendment agreements and shall automatically terminate if employment with the Employer is terminated.
Employee further understands and agrees that Employee:
- Is responsible for notifying TDS if the Employee is currently contributing to another 403(b), 401(k) or 401(a) at the time this salary reduction agreement is signed. Furthermore, the Employee agrees to notify TDS in the event the Employee begins to contribute to another 403(b), 401(k) or 401(a) plan.
- Is responsible for determining that annual salary reduction contributions to all elective deferral plans do not exceed the limits of the Applicable Law.
- Is responsible for identifying that portion of his/her contribution which is a Roth 403(b) contributions and which portion is a pre-tax 403(b) contribution so that investment providers can properly segregate contributions or apply separate accounting to independently track and monitor each type of contribution.
- Is responsible for the accuracy of the information provided by Employee, which may be used in determining Employee's maximum annual contribution limit.
- Is solely responsible for any losses suffered by Employee that result from his/her participation in the 403(b) plan and that Employer has no liability for investment performance of Employee’s account(s).
- Acknowledges that Employer has made no representation regarding the advisability, appropriateness or tax consequences of the purchase of the 403(b) plan. Nothing herein shall affect the terms of employment between Employer and Employee.
- Acknowledges and authorizes Employer to share information on employee’s account(s) with investment providers and/or plan administrators for compliance purposes.
Although Employer must authorize Investment Providers, Employer does not choose the annuity contract(s) or custodial
account(s) in which 403(b) contributions are invested. Employee is responsible for setting up and signing the legal documents
to establish the annuity contract or custodial account, which must be established prior to submission of this Agreement.
Employers are responsible for all distributions and any other transactions with the Investment Provider(s). All rights under the
annuity contracts or custodial accounts are enforceable solely by Employee, Employee’s beneficiary or Employee’s
authorized representative. However, Employer has certain responsibilities under the 403(b) Plan with respect to the integrity
of the transactions for the Plan and may require an authorized representative from Employer to approve any requested
transactions by Employees. Employee must cooperate directly with any Investment Provider or Employer representative, as
directed by Employer to exchange contract(s) or custodial account(s) to another Investment Provider, make distributions,
request loans, exchanges or otherwise access 403(b) Plan assets.
Employee understands that Employer is authorized to utilize the services of a Plan Administrator at the discretion of the
Employer and, as such, Employer may direct the amount of any salary reduction/deduction to the Plan Administrator with the
intent of having Plan Administrator distribute such funds to the designated Investment Provider.
Employee understands that the Plan Administrator charges each Investment Provider an administration fee of $3.00 per
month for each annuity or custodial account administered in the Plan. In the event the Investment Provider selected above
does not agree to pay the administration fee, Employee authorizes and directs Employer to deduct the administration fee
directly from Employee’s paycheck each month through an after-tax payroll deduction.
I certify that I have read this complete Agreement and that my contributions to the 403(b) Plan do not result in a contribution
amount that exceeds the contribution limits under Applicable Law. I understand my responsibilities as an Employee under the
403(b) Plan, and by signing this Agreement, I direct Employer to take the actions specified in this Agreement unless deemed
inappropriate by my Employer or Plan Administrator.
By signing this Agreement, I authorize any Investment Provider, the 403(b) Plan Administrator, my Employer or their
representatives to provide information on my account(s) that may be necessary for compliance purposes or to effectuate
such transactions as I may request.
By clicking the button below labeled "Continue", I hereby confirm that I have read and understand all information contained in this Agreement.
Re-enter Social Security # to verify (9-digit format, no dashes or spaces)