DOE OHR 100-003
STATE OF HAWAII DOE
Last Revised: 08/04/2014
Former DOE Form(s): 403(b)SRA
403(b) PLAN/ SALARY REDUCTION
DEPARTMENT OF EDUCATION
Office of Human Resources
AGREEMENT
Health Benefits and Awards Unit
P.O. Box 2360 Honolulu, HI 96804
I. EMPLOYEE INFORMATION
Name: _____________________________________________________________
SSN: _______________________________
Last
First
M.I.
City: _____________________ State: _______ Zip: ______________
Home Address: ____________________________________
Tel#: ________________________
E-mail Address: ___________________________________________________
Check One:
Classified
Certificated
School/Office: ______________________________
II. EFFECTIVE DATE
Note: Enter the pay date you intend the instructions provided in this form to be effective. Instructions shall
From: _______________________
be implemented in accordance with the State of Hawaii Department of Education (DOE) administration
MM/DD/YYYY
schedule.
III. CONTRIBUTION INFORMATION
Check all that apply and complete the TSA Service Provider(s) Section, as needed. Please note that you or your agent must contact your investment provider(s)
separately in order to establish the accounts(s) which will receive contributions.
Initiate new salary reduction - Reduce my salary by the monthly amount of $ _____________ or _________% and forward to the
TSA Service Provider(s) indicated below in the TSA Service Provider(s) Section.
Change current salary reduction amount - Change my current monthly salary reduction amount from: $ _____________ or
_________% to: $ _____________ or _________%.
Change TSA Service Provider(s) - Change my TSA Service Provider(s) as indicated below in the TSA Service Provider(s)
Section and reduce my salary by the monthly amount of $__________ or __________%. Be sure to indicate providers you wish
to stop contributions to by indicating 0% or $0.
Lump Sum Deferral $_______________
Post-Separation Vacation Pay Deferral - Vacation pay dollar amount to defer: $ _____________
Cancel salary reduction due to HARDSHIP - Discontinue my salary reduction.
Date of hardship: ____________________
MM/DD/YYYY
Cancel salary reduction - Discontinue my salary reduction.
IV. TSA SERVICE PROVIDER(S)
Indicate the % or $ amount of your salary reduction that you would like to be allocated to your desired TSA Service Provider(s). Please see Page 2 for examples.
Note that if you have selected a percentage of your salary to be deferred, you may only utilize % allocations. All accounts must be established with the listed
fund company prior to submitting the SRA. Salary reduction will not be executed if you have not established your account(s).
TSA Service Provider
Service
Have you established an account
Percent
Dollar
Provider Code
with this provider?
(Custodian, Insurance Carrier, or Investment Provider name)
% or $
_________________________________________
Yes
No
% or $
_________________________________________
Yes
No
% or $
_________________________________________
Yes
No
% or $
_________________________________________
Yes
No
V. EMPLOYEE CERTIFICATION
I certify that I have read this complete agreement. I understand my responsibilities as an employee under this Program and I request that the Department of
Education take the action specified in this agreement. I understand that all rights under the annuity or custodial account(s) established by me under the Program
are enforceable solely by me, my beneficiary or my authorized representative.
Employee Signature: ______________________________________________________
Date: _______________________
MM/DD/YYYY
(Page 1 of 3)
Distribution: Original - OHR, Health Benefits and Awards Unit