Salary Deferral Agreement - Roth - The Retirement Advantage Page 2
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2SECTION 3: SPECIAL ELECTION FOR BONUSES
(Complete this section if Plan allows special elections for bonuses AND you wish to
apply a special election to bonuses)
I elect NOT to withhold from my bonus at this time.
I authorize the Employer to withhold from my bonus and treat as PRE-TAX salary deferrals the
following amount:
_______% or $__________ of my bonus which is to be paid on ___________________
__________, 2__________ (insert date). In making this election, I do not intend to change my
existing Salary Deferral Agreement (if any) as to Compensation other than the bonus described in
this Agreement (if allowed by Plan).
_______% or $__________ of ALL bonuses paid to me on or after __________________
_________, 2___________ (insert date). In making this election, I do not intend to change my
existing Salary Deferral Agreement (if any) as to Compensation other than the bonus described in
this Agreement (if allowed by Plan).
AND/OR
I authorize the Employer to withhold from my bonus and treat as ROTH salary deferrals the following
amount:
_______% or $__________ of my bonus which is to be paid on ___________________
__________, 2__________ (insert date). In making this election, I do not intend to change my
existing Salary Deferral Agreement (if any) as to Compensation other than the bonus described in
this Agreement (if allowed by Plan).
_______% or $__________ of ALL bonuses paid to me on or after __________________
_________, 2___________ (insert date). In making this election, I do not intend to change my
existing Salary Deferral Agreement (if any) as to Compensation other than the bonus described in
this Agreement (if allowed by Plan).
I understanding that I can change this election at any time by completing a new Salary Deferral
Agreement.
SECTION 4: REQUIRED SIGNATURES
Duty to Review Pay Records. I understand I have a duty to review my pay records (pay stub, etc.) to confirm the
Employer has properly implemented my salary deferral election. Furthermore, I have a duty to inform the Plan
Administrator if I discover any discrepancy between my pay records and this Salary Deferral Agreement. I
understand the Plan Administrator will treat my failure to report any withholding errors for any payroll to which my
Salary Deferral Agreement applies, by the cut-off date for the next following payroll, as my affirmative election to
defer the amount actually withheld (including zero). However, I thereafter may modify my salary deferral election
prospectively, consistent with the current Plan Document.
I understand that it may be necessary for the Plan to limit my contribution election in accordance with Plan and/or IRS
limitations. Once money is contributed to the Plan, I understand that money will only be distributable upon my death,
permanent disability, retirement or termination of employment; and if allowed by the Plan, may be withdrawn in the
event of serious financial hardship, a Plan loan and/or attainment of a specified age (59 ½ or later). All distributions
will be verified for compliance with current Plan provisions and IRS regulations.
I understand that if I have elected life insurance through the Plan, minimum contributions may have to be made to the
Plan to meet IRS guidelines. Therefore, I must contact the Plan Administrator if I am decreasing my contributions.
Further, if I am reducing my contribution to 0% and have life insurance through the Plan for which premiums can no
longer be paid with funds from the Plan, I must make an election concerning my life insurance coverage.
___________________________________________________
_______________________
Participant Signature
Date
PLEASE RETURN THIS FORM TO THE PLAN ADMINISTRATOR
2/10
Salary Deferral Agreement – Roth
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