Doe Ohr 100-003 - State Of Hawaii Doe 403(B) Plan/ Salary Reduction Agreement Page 3

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DOE OHR 100-003

Last Revised: 08/04/2014

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

IMPORTANT INFORMATION

1. The DOE does not choose the annuity contract or custodial account in which the Employee's contributions are invested.

2. The Employee is responsible for setting up and signing the legal documents to establish the annuity contract or custodial account.

3. The Employee, not the DOE, is to be identified as the contract/certificate/account holder.

4. In order for the Employee to receive the expected tax results, the annuity contract or custodial account established must meet the requirements of Section

403(b) of the Internal Revenue Code. It is solely the Employee’s responsibility to establish the proper type of contract or account for this purpose.

5. The Employee is responsible for naming a death beneficiary under the annuity contract or custodial account. This is normally done at the time the contract or

account is established, although the designation should be reviewed from time to time.

6. The Employee is responsible for investment decisions, distributions and any other transactions with the insurance company or investment company and shall

have total responsibility for all distributions and any resulting taxation consequences. All rights under the contract or account are enforceable solely by the

Employee, the Employee’s beneficiary or the Employee’s authorized representative. The Employee must deal directly with the insurance company or investment

company to make loans, transfer to different contracts or investment accounts, begin distributions, or to handle any other transactions. However, the DOE

reserves the right to alter this policy if deemed necessary to comply with State or Federal law.

7. The Employee understands that information contained in this Agreement and other non-public information may be shared with the DOE's designated third-

party administrator in conjunction with the operation of the TSA Program.

8. Retain a copy of this form and submit original to:

National Benefit Services, LLC

Attn: Hawaii DOE 403(b)

8523 S. Redwood Road

West Jordan, UT 84088

Fax: (800) 597-8206

(Page 3 of 3)

Distribution: Original - OHR, Health Benefits and Awards Unit