Form Fx-0003-0503 Additional Contributions Tax-Sheltered (Acts) Program Salary Reduction Agreement
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1
2FX-0003-0503
PO Box 295
STATE OF NEW JERSEY
Trenton, NJ 08625-0295
DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
ADDITIONAL CONTRIBUTIONS TAX-SHELTERED (ACTS) PROGRAM
SALARY REDUCTION AGREEMENT
Name
__________________________________________
_____________________________
_________________
LAST
FIRST
MIDDLE INITIAL
Social Security No.
Retirement
PERS
Membership No.
(IF APPLICABLE)
__________________________________
System
TPAF
___________________________
PFRS
(IF APPLICABLE)
Address _____________________________________________________________________________________________
STREET OR R.D.#
APARTMENT NO.
________________________________________________________________________________________________
CITY
STATE
ZIP
Daytime Telephone Number ( ____________ ) _____________________________________________________________
The above named employee and the State of New Jersey agree that the employee’s eligible earned base biweekly
salary will be reduced by voluntary contributions beyond those required by mandatory membership in any state-admin-
istered retirement system. The amount of reduction shall be ____________% and will take effect on the date certified
below. This reduction shall not exceed the employee’s statutory exclusion allowance under Section 403(b) or the
limitations of Section 415 and the regulations thereunder of the Internal Revenue Code. The voluntary contributions
will be allocated and forwarded as directed on the employee’s most recent Carrier Election and Allocation form.
This agreement shall be legally binding as to each of the parties hereto while employment continues; provided that
either party may terminate this agreement as of the end of any month, so that it will not apply to salary subsequently
earned, by giving at least 30 days written notice of the date of termination; and provided further, that no more than one
agreement for such salary reduction may be made within any calendar quarter.
Check one:
Initial Agreement
Change Percentage
Suspend Contributions
- (LIMITED
TO ONE PER CALENDAR QUARTER)
Employee Signature: ________________________________________________
Date: ____________________________
EMPLOYER SECTION
Name of
Employing Agency ___________________________________________________
Payroll No. ______________________
Address of Employing
Agency ______________________________________________________________________________________________
Certifying Officer
Signature ___________________________________________
Title __________________________________________
Telephone Number ____________________________________
Date __________________________________________
Mail completed form to: Division of Pensions & Benefits, ACTS Program, PO Box 295, Trenton, NJ 08625-0295
FOR DIVISION USE ONLY
SALARY REDUCTION AGREEMENT - CONFIRMATION OF RECEIPT BY DIVISION OF PENSIONS AND BENEFITS
Effective
Authorized
Date ______________________ Signature ______________________________________ Date ______________
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