PlanScope360 - Salary Reduction

Salary Reduction Agreement

= Required

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Employer State

Employer

First Name

Middle Initial

Last Name

Birth Date

SSN

Work Email

Work Phone format: 999-999-9999

IMPORTANT: The reduction agreement below replaces and cancels all previous salary reduction agreements for you.
Contribution amounts are per paycheck.

I want to stop contributions

Plan Type

Plan Provider

Contribution Amount

Amount Format

Dollars Amount is percent

Advisor Name

Advisor Email

Comment

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(b) annuity or custodial account(s) selected by employee and authorized by the employer, properly identifying pre-tax contributions and post-tax Roth 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.