Salary Reduction Agreement - Supplemental Retirement Account (Sra) 403(B) And 457(B) Plan(S) - Wvsom Page 2

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PART II – VENDOR SELECTION (Select only one vendor per SRA)

After a review of the materials provided by the vendors, I elect to participate in the 403(b) and/or the 457(b) program provided by:

403(b) -Select only one choice.

457(b) – Select only one choice

Great West

TIAA-CREF

Note: Only for new enrollees, a separate TIAA-CREF or Great West enrollment form for the selected vendor must be completed and

submitted along with this form.

PART III – SIGNATURE VERIFICATION & EFFECTIVE DATE

Upon completion and signature of this Agreement, please return it to the WVSOM Benefits Office. The submission of this Agreement

will replace any prior Salary Reduction Agreements you have made for these plans.

Requested effective date of payroll change*: _______________

*The effective date shall be the beginning of the next payroll cycle following the date this form is received by the FSU Benefits Office, or as soon as the form is able to

be keyed. Be aware payroll “cutoff” is substantially earlier than the actual pay date (i.e., the last day information can be changed for the end of the month is typically

mid-month).

Employee Signature: _____________________________________

Date: _________________

RETURN THIS FORM WITH THE ENROLLMENT FORM (IF NEEDED) TO:

WVSOM Office of Business Affairs

A235, Quad (A Building)

**************************************************************************************************

Internal Use Only

Accepted on behalf of Employer by: _____________________________________

Date: __________________

403(b)

Total deferral amount per pay $_____________