Tax-Deferred Retirement Account (Tdra) Enrollment Form For Selfemployed Ministers Page 3
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3V. APPLICANT CERTIFICATION AND SIGNATURE
By completing and submitting this Enrollment Form, I am requesting to make pre-tax contributions to the TDRA from my earned
income from the exercise of my ministry. I understand that my total pre-tax contributions for a calendar year generally cannot exceed
the limit under Section 402(g) of the Internal Revenue Code ($18,000 for 2015, indexed for cost of living thereafter), increased if
applicable by the 15 years of service catch-up (up to $3,000 each year depending on prior pre-tax contributions, but no more than
$15,000 for a lifetime) and/or the age 50 catch-up ($6,000 for 2015, indexed for cost of living thereafter).
I agree to be bound by all terms of the TDRA, as it may be amended from time to time, and all administrative policies and procedures
adopted by Pension Fund with respect to the TDRA. I understand that I will be mailed a copy of the Tax-Deferred Retirement
Account Member Resource Book upon Pension Fund's receipt of this Enrollment Form, and that I can also access the Member
Resource Book and other information regarding the TDRA electronically at
I certify that my contributions to the TDRA satisfy the following:
•
The contributions are from my earned income from the exercise of my ministry as a self-employed minister.
•
The contributions do not exceed 100% of my self-employment income from the exercise of my ministry.
•
The contributions do not relate to any compensation from my employment with an employer.
•
The contributions do not include any after-tax contributions.
•
The contributions would be includible in my taxable income from self-employment if it were not being contributed to the
TDRA.
I certify that the information provided on this Enrollment Form is accurate. I further certify that I understand the tax requirements for
making pre-tax contributions to the TDRA and the potential tax consequences of making ineligible contributions. I understand that
Pension Fund is relying on the factual accuracy of my certification in allowing me to contribute to the TDRA. I agree that I will
notify Pension Fund of any changes to the information provided on this Form, including a change in my self-employment status
or in my eligibility to make contributions. I understand that Pension Fund may require me to recertify this information on an annual
basis.
I designate the person(s) or entity(ies) named in Section III of this Enrollment Form as beneficiaries for my 403(b) account under the
TDRA. I reserve the right to revoke this designation at any time by submitting a new Beneficiary Designation Form. I understand that
my beneficiary designation on this Enrollment Form will remain in effect until I complete, sign, and submit an updated Beneficiary
Designation Form to Pension Fund at a later date. I certify that I have secured spousal consent if I have named a beneficiary other than,
or in addition to, my spouse to the extent I reside in a community or marital property state and am required to secure such consent by
state law with respect to all or a portion of my 403(b) account. I assume complete responsibility for all consequences if I fail to obtain
any required consent
Applicant Signature
Date ________/________/________
SEND FORM WITH INITIAL CONTRIBUTION TO:
Pension Fund of the Christian Church
P.O. Box 6251, Indianapolis, Indiana 46206-6251
Toll Free: 1.866.495.7322 • Phone: 317.634.4504 • Fax: 317.634.4071
E-mail:
• Website:
Membership No. _____________________
PIN No. ________________________
Enrollment Date ________/________/________
Initial Contribution Amount Remitted
$______________________________
[Do not write in this box – for Pension Fund use only]
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TDRA Enrollment Form for Self-Employed Ministers 03-15
4927828v2
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