Form Fx-0003-0503 Additional Contributions Tax-Sheltered (Acts) Program Salary Reduction Agreement (Page 2 of 2) in pdf

FX-0003-0503

ADDITIONAL CONTRIBUTIONS TAX-SHELTERED (ACTS) PROGRAM

SALARY REDUCTION AGREEMENT

GENERAL INFORMATION

Employees of county colleges, state universities and colleges, the Commission on Higher Education, the

Department of Education, and the Office of Student Assistance can participate in the Additional Contributions

Tax-Sheltered (ACTS) Program. ABP members have the option to select the same individual carriers

through the regular Alternate Benefit Program.

The Salary Reduction Agreement establishes a contract between you and the State of New Jersey. A

Salary Reduction Agreement must be filed to establish participation and each time you change your

percentage of reduction. However, only one ACTS Salary Reduction Agreement initiating a change may

be filed per calendar quarter. For this purpose, the suspension of contributions does not constitute a

change. If you are a new participant, this form must be accompanied by the Carrier Election and Allocation

form. A Carrier Election and Allocation form must be filed to identify the investment carrier(s) with which

you want your contributions invested.

INSTRUCTIONS FOR APPLICANTS

Please read all information carefully when completing this form. Where applicable, indicate your name,

mailing address, social security number, and telephone number where you may be reached during daytime

working hours. If you are a member of a state-administered retirement system, check the name of the

system and provide your membership number.

To authorize the reduction, indicate the percentage (in whole numbers only) of your base salary you elect

to invest with any eligible carrier(s). The reduction amount shall not exceed your statutory exclusion

allowance under Section 403(b) or the limitations of Section 415 and the regulations of the Internal Revenue

Code. Indicate in the relevant box if this is an initial agreement, change, or suspension of contributions.

Sign and date the form and have your certifying officer complete the employer information. A copy will

be returned to you after confirmation of receipt indicating the date your reduction will take effect.

Refer to the Carrier Comparison Guide for information on individual carriers. Before submitting forms to

the ACTS Program, it is your responsibility to complete the necessary forms to establish a valid account

with the carrier(s) you select for your investments. If you fail to establish an account with the carrier(s), you

may lose earnings from your contributions. Additionally, the carrier(s) will return your contributions to the

Division of Pensions and Benefits and your participation will be delayed.

INSTRUCTIONS FOR EMPLOYERS

Please enter the name, address, and payroll number of your agency. The designated certifying officer must

sign the form indicating his/her title, telephone number, and the date. Upon completion, return this form to:

DIVISION OF PENSIONS AND BENEFITS

ACTS PROGRAM

PO BOX 295

TRENTON, NJ 08625-0295

Form Fx-0003-0503 Additional Contributions Tax-Sheltered (Acts) Program Salary Reduction Agreement Page 2