403(B) Salary Reduction Authorization And Amendment Form
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2403(b) SALARY REDUCTION AUTHORIZATION AND AMENDMENT FORM
Pursuant to the provisions and conditions set forth on the bottom of this page, I hereby request and authorize the Payroll Department
________________________________________________
of
to reduce my salary by the amount indicated and direct the
amount of such reduction to the Insurance and/or Mutual fund Company specified below.
Employee Information
Employee Full Name: ___________________________________________________
Date of Birth: ____________________
Social Security Number: ____________________________
Work Site: ____________________________________________
Date of Hire: ______________
Day Phone: __________________________
Evening Phone: __________________________
Employee Contribution per Pay Period: $_________________
10 pay
11 pay
12 pay
other ____________
Effective Date of Change: _____/_____/________
Employee Annual Contribution: $_________________
Transaction Information
CHECK ALL THAT APPLY:
Increase in contribution amount
Decrease in contribution amount
New Contribution
Change in Company
Additional Company
Stop all contributions
Vendor Company Information
INSURANCE COMPANY / MUTUAL FUND TO RECEIVE 403(b) CONTRIBUTIONS:
403bcompare
__________________________________________
$__________
_______________
Name of Company:
Amount:
Number*:
Company Address: ____________________________________________________________________________________________
403bcompare
__________________________________________
$__________
_______________
Name of Company:
Amount:
Number*:
Company Address: ____________________________________________________________________________________________
403bcompare
__________________________________________
$__________
_______________
Name of Company:
Amount:
Number*:
Company Address: ____________________________________________________________________________________________
* 403bcompare Number applies only to public school entities within California
Cancellation Information
CANCELLATION REQUEST – Please cancel contributions to the following companies:
_____________________________________________________
__________________________________________________
Company Name
Company Address
_____________________________________________________
__________________________________________________
Company Name
Company Address
SALARY REDUCTION AUTHORIZATION AND AMENDMENT TO EMPLOYMENT CONTRACT
It is agreed that the wages earned or contract of employment between the Employer and the below-signed Employee is amended as of
the Effective Date of change listed so that thereafter, the Employer is requested and authorized by Employee to reduce the amount of
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