Form Hr 17 - Tda Salary Reduction Agreement/change Of Vendor Form
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HR 17 (
)
The T
The T
The T
The T
The Texas A&M University System
exas A&M University System
exas A&M University System
exas A&M University System
exas A&M University System
TDA Salar
TDA Salar
TDA Salar
TDA Salar
TDA Salary Reduction Agr
y Reduction Agr
y Reduction Agr
y Reduction Agreement/Change of V
y Reduction Agr
eement/Change of V
eement/Change of V
eement/Change of Vendor For
eement/Change of V
endor For
endor For
endor Form m m m m
endor For
With few exceptions, you have the right to request, receive, review and correct information about yourself collected using this form.
Before completing this form, read and follow the instructions on page three.
____________________________________________________
_____________________
________________________
Name (Print)
Social Security number or UIN
Daytime telephone
____________________________________________________
________________________________________________
Department
Agency/institution name
A. EFFECTIVE DATE
The following election to participate in either type of Tax-Deferred Account will be effective for:
Option 1: the next available payroll,
Option 2: specify paydate____________________, or
Option 3: upon termination or retirement, defer my lump-sum vacation pay.
As authorized by the provisions of Section 403(b), United States Internal Revenue Code, The Texas A&M University System is hereby
authorized to reduce my future compensation to purchase for me a nonforfeitable 403(b)(1) or 403(b)(7) Tax-Deferred Account as
described below.
B. SELECT/CHANGE CONTRIBUTION AMOUNT AND SELECT VENDOR (if changing vendor only, see section C)
Reduce my gross compensation by $__________________ (fixed dollar amount) or _______% (percentage) per month for deposit
in a Tax-Deferred Account. Allocate this amount with the vendor(s) listed below as indicated.
Upon termination or retirement, defer $________________ or _______% of my lump-sum vacation pay for deposit in a Tax-
Deferred Account. Allocate this amount with the vendor(s) listed below as indicated.
Regular TDA (your contributions are not taxed, but your earnings are)
Regular TDA (your contributions are not taxed, but your earnings are)
Regular TDA (your contributions are not taxed, but your earnings are)
Regular TDA (your contributions are not taxed, but your earnings are)
Regular TDA (your contributions are not taxed, but your earnings are)
Dollar Amount/Percentage ______________________ Vendor #1 _________________________
Dollar Amount/Percentage ______________________ Vendor #2 _________________________
Roth TDA (your contributions are taxed, but your earnings are not)
Roth TDA (your contributions are taxed, but your earnings are not)
Roth TDA (your contributions are taxed, but your earnings are not)
Roth TDA (your contributions are taxed, but your earnings are not)
Roth TDA (your contributions are taxed, but your earnings are not)
Dollar Amount/Percentage ______________________ Vendor #1 _________________________
Dollar Amount/Percentage ______________________ Vendor #2 _________________________
This Salary Reduction Agreement will be in effect until (1) a new agreement is submitted, (2) the calculated maximum as determined by
the A&M System is reached, (3) the end of the month during which the Human Resources or Payroll office receives my written request
to stop the TDA salary reduction agreement, or (check one of the following):
indefinitely and deducted on a 12-month basis;
indefinitely and deducted on an academic-year basis (9-month basis for September through May only);
through the end of this calendar year only (in which case the stop date will be Dec. 31 and another agreement must be submitted
for future calendar year participation);
for _____ (number) months during this calendar year, ___________________ through ___________________,
upon termination or retirement, a one-time lump-sum deferral.
In the calendar year for which this agreement applies, have you made: 401(k) salary reduction contributions or SIMPLE 401(k)
contributions with any employer, 408(k)(6) salary reduction SEP amounts or 408(p) SIMPLE IRA amounts with any employer, 403(b)
salary reduction contributions with employers other than the A&M System, or any 501(c)(18) plan elective deferrals?
Yes (Amount: $___________________)
No
This agreement is inclusive as written and supersedes all previous agreements. Existing vendors will be amended or continued only to
the extent specifically stated above. Contributions to existing vendors not indicated on this agreement will be terminated.
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Parent category: Business