PlanScope360 - Salary Reduction

Salary Reduction Agreement

= Required

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Employer State

Employer

Employee ID Number

Pay Frequency

First Name

Middle Initial

Last Name

Birth Date

SSN (last 4)

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone format: 999-999-9999

Work Phone format: 999-999-9999

Work Email

IMPORTANT: The reduction agreement below replaces and cancels all previous salary reduction agreements for you.

Agreement Type

Plan Type

Investment Provider

Start Date

Amount Per Pay Period

Dollars Percent

Agent/Advisor Name

Agent/Advisor Email

Comment

All contributions/deductions that are not listed on this form will cease to be deducted from your paycheck and will no longer be contributed to your 403(b) or 457 account.

By submitting this form, employee agrees to modify his/her salary as indicated above and employer agrees to contribute this amount on employee’s behalf into the 403(b)/457 annuity or custodial account(s) selected by employee and authorized by the employer, properly identifying pre-tax contributions and post-tax Roth 403(b) contributions for proper allocation to segregated accounts by the service provider.

By submitting this form, I authorize any service provider or their delegate to provide information on my account to employer or another service provider, if such information is necessary for compliance purposes or to effectuate such transactions as I may request.