Doe Ohr 100-003 - State Of Hawaii Doe 403(B) Plan/ Salary Reduction Agreement Page 2

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DOE OHR 100-003

Last Revised: 08/04/2014

Former DOE Form(s): 403(b)SRA

VI. AGENT CERTIFICATION (Optional)

I agree to comply with all pertinent written directives regarding solicitation of DOE employees. Furthermore, I agree to indemnify and

hold harmless the State of Hawaii Department of Education, National Benefit Services, LLC, and the Employee participating in the TSA

Program against any claims arising from my solicitation of the said Employee.

Name of Agent:_________________________________________

Agent Signature: ______________________________________________________

Date: _______________________

MM/DD/YYYY

Tel#/Fax#: ____________________________________________

E-mail Address: _____________________________________

DEPARTMENT OF EDUCATION USE ONLY

Date Received: ___________________________

Initials: _________

MM/DD/YYYY

TSA SERVICE PROVIDERS SECTION EXAMPLES

Suppose your current salary reduction is a specific dollar amount ($500) of your monthly pay--all of which is currently contributed to service provider ABC.

Now you wish to add an additional monthly contribution of $200 to a new service provider--XYZ. You must mark "Initiate new salary reduction" and indicate

$200 in the Contribution Information Section. You must also indicate $200 to XYZ in the TSA Service Providers Section. This will leave your original salary

reduction unchanged and add your new one. Note: the procedure is the same for percentage deferrals. Example:

200

% or $

XYZ Annuity Company

Suppose your current salary reduction is 2%, contributed to service provider ABC, but you would like to stop contributing to ABC and instead contribute 2% to

XYZ. You must mark "Change TSA service provider(s)" in the Contribution Information Section and change the allocation to ABC to 0% and add 2% to XYZ in

the TSA Service Providers Section. Note: the procedure is the same for dollar amount deferrals. Example:

% or $

ABC Annuity Company

% or $

XYZ Annuity Company

TERMS OF AGREEMENT

The above named Employee agrees to modify his/her salary as indicated above. The Department of Education (DOE) agrees to contribute this amount on the

Employee’s behalf into the annuity or custodial accounts selected by the Employee. It is intended that the requirements of all applicable state or federal income

tax rules and regulations (Applicable Law) will be met.

The Employee understands and agrees to the following: 1) this Salary Reduction Agreement is legally binding and irrevocable with respect to amounts paid or

available while this agreement is in effect; 2) this Salary Reduction Agreement may be terminated at any time with respect to amounts not yet paid or available,

and that a termination request is permanent and remains in effect until a new Salary Reduction Agreement is submitted; 3) this Salary Reduction Agreement may

be changed with respect to amounts not yet paid or available in accordance with the Employer’s administration procedures; 4) the salary reductions are subject to

the maximum allowable contribution (MAC), and by executing this agreement, acknowledges that the DOE has the authority to stop reductions at any time to

assure that the Employee’s annual contribution amount is in compliance with federal and state law requirements; and 5) that the MAC calculated by the Agent is

based on the Employee’s eligible income which is subject to change and that any changes to the Employee’s eligible income will affect the MAC.

The Employee agrees to indemnify and hold the DOE and National Benefit Services, LLC (NBS) harmless against any and all actions, claims and demands

whatsoever that may arise from the purchase of annuities or custodial accounts in this TSA Program. The Employee acknowledges that the DOE has made no

representation to the Employee regarding the advisability, appropriateness or tax consequences of the purchase of the annuity and/or custodial account described

herein. The Employee agrees that neither the DOE nor NBS shall have any liability whatsoever for any and all losses suffered by the Employee with regard to

his/her selection of the annuity and/or custodial account; its terms; the selection of the insurance company or regulated investment company; the solvency of,

operation of or benefits provided by said insurance company or regulated investment company; or his/her selection and purchase of shares of regulated

investment companies. Nothing herein shall affect the terms of employment between the DOE and Employee.

The DOE reserves the right to alter terms of this Agreement as required to facilitate Program compliance with State and Federal law.

This agreement supersedes all prior Salary Reduction Agreements and shall automatically terminate if Employee’s employment is terminated or DOE terminates

the TSA Program. Any participant found to be in violation of the DOE’s TSA Program shall have their salary reduction agreement(s) terminated.

(Page 2 of 3)

Distribution: Original - OHR, Health Benefits and Awards Unit