Salary Deferral Agreement - Roth - The Retirement Advantage
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2SALARY DEFERRAL AGREEMENT
(Including Roth Salary Deferrals)
Plan Name: ______________________________________________________________________
Participant Name: _________________________________________________________________
Print or Type Complete Legal Name – First, MI, Last
Social Security Number: ___________________________________________________________
Street Address: ___________________________________________________________________
City: _____________________________
State: ______________
ZIP: ____________
Check One:
New Agreement
Change
Bonus Election
SECTION 1: SALARY DEFERRAL ELECTION
Salary Reduction/Deferral Amount. This Agreement is effective as of the next enrollment or change
date as provided for in the current Plan Document. I may modify this Agreement only in accordance with
current Plan provisions and IRS regulations.
I authorize the Employer to withhold from my Compensation (and treat as salary deferrals) the
following amount:
$__________ or ______% of my per pay period Compensation as pre-tax salary deferrals
$__________ or ______% of my per pay period Compensation as Roth salary deferrals
Zero for pre-tax salary deferrals. I hereby terminate my prior Salary Deferral Agreement of pre-tax
salary deferrals. (Note: Elect “zero” only if you wish to terminate pre-tax salary deferrals under a prior
Salary Deferral Agreement currently in effect.)
Zero for Roth salary deferrals. I hereby terminate my prior Salary Deferral Agreement of Roth salary
deferrals. (Note: Elect “zero” only if you wish to terminate Roth salary deferrals under a prior Salary
Deferral Agreement currently in effect.)
Deferrals irrevocable once made. I understand: (1) my election regarding the amount and type of
deferrals is irrevocable once the employer withholds the deferrals from my paycheck; and (2) any change
of election regarding the amount or type of deferrals is effective only for deferrals from paychecks I
receive after the Plan Administrator accepts my change of election.
SECTION 2: ELECTION TO NOT DEFER
(Note: Non-deferring Participants will be included in annual Plan testing)
I elect NOT to defer into the Plan at this time. (Note: Elect this only if you have no Salary Deferral
Agreement currently in effect and wish NOT to defer.)
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Salary Deferral Agreement – Roth
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