(TSA) SALARY REDUCTION REQUEST FORM

403(b) TAX SHELTERED ANNUITY (TSA) SALARY REDUCTION REQUEST FORM
Complete and return this form to Campus Benefits Representative. Retain attached Salary Reduction Agreement for your records.
Please note: You may contribute to no more than two (2) TSA companies at a time. The minimum monthly salary deferral is $15.
Last Name, First /Middle Initial
SSN*:
Year of Birth:
Indicate Full-Time, Part-time or FERP Participant
Telephone Contact (Work or Home)
E-mail Address (Optional)
Section A. Please Answer the Following Questions Regarding Your Contributions:
1. What is your projected total amount of contributions to the following plans for the current tax year?
¾ CSU 403(b) Tax Sheltered Annuity (TSA) Program
____________.___
¾ Department of Personnel Administration (DPA) Savings Plus Program 401(k) plan
____________.___
Total annual projected contribution: ____________.___
2. Are your projected contributions to the 403(b) and 401(k) plans for this tax year over the current annual maximum?
□ YES □ NO? If NO, proceed to sections B - E. If YES, proceed to question 3.
3. Do you have 15 years or more of CSU service? □ YES □ NO? If NO, proceed to question 4. If YES, a completed Maximum Contribution
Allowance Worksheet is required, and must be submitted for each tax year that you plan to contribute beyond the annual maximum. If you
previously submitted a Worksheet for the current year, proceed to sections B - E.
4. Will you be age 50 in the current year? □ YES □ NO? If NO, you may not exceed the annual maximum. Proceed to sections B – E. If
YES, you may participate in the Age 50 catch-up allowance. Proceed to sections B – E.
Section B. To make changes to current TSA Investments, complete items 1 and/or 2 below to indicate current salary deferral(s) and changes:
1) Name of TSA Company:
2) Name of TSA Company:
____________________________
____________________________
Deduction Code: __ __ __ - __ __ __
Deduction Code: __ __ __ - __ __ __
Change Requested:
CANCEL
NO CHANGE
CHANGE AMOUNT
Change Requested:
CANCEL
NO CHANGE
Current Deferral Amount: $ _________
Current Deferral Amount: $ ________
New Deferral Amount:
New Deferral Amount:
$ _________
CHANGE AMOUNT
$ ________
Section C. For new TSA investments, complete items 1 and/or 2 below to begin salary deferral(s) and/or restart previously canceled deferrals:
1) Name of TSA Company:
2) Name of TSA Company:
____________________________
____________________________
Deduction Code: __ __ __ - __ __ __
Deduction Code: __ __ __ - __ __ __
Deferral Amount: $ _______
Deferral Amount: $ ___________
Account Number: ______________________________
(Proof of established TSA account is required.)
Account Number: ___________________________________
(Proof of established TSA account is required.)
Section D. Total Salary Reduction**. Please provide the total dollar amount of the deferral(s) requested, and the month it should begin:
The CSU shall reduce each regular monthly installment of salary due you, the Employee, under the terms of your appointment by a
total reduction amount of $__________ per month, as allocated above, beginning with the pay warrant issued on _____/______
(month/year) for the ______/______ (month/year) pay period. I understand that if this request is not submitted to the campus
Benefits Representative in a timely manner, the effective date of this request may be delayed. This Agreement will not be effective
for any salary made available prior to the date this Agreement is signed.
Section E: Employee Certification.
I certify that I have read the complete CSU Salary Reduction Agreement and that my salary reduction(s) does not exceed contribution limits
as determined by applicable Internal Revenue Code. I understand my responsibilities as an Employee under the CSU 403(b) Tax Sheltered
Annuity (TSA) Program, and I make application to the CSU pursuant to Education Code Section 89505 for purchase of a 403(b) plan contribution
and reduction in salary under the terms of this agreement.
The CSU and Employee agree to the foregoing terms of this agreement.
Employee Signature _________________________________
Date ___________
Accepted by Authorized Campus Representative __________________________________
Date ___________
*Your Social Security number is required because it is your payroll identification number, and this agreement affects payroll transactions.
**Please note: The annual tax year begins with the December pay period and ends with the November pay period of the following year.
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403(b) Tax Sheltered Annuity (TSA) Salary Reduction Agreement
1.
Authority: Title 26, United States Code Section 403(b), Education Code Section 89505, and California Code of Regulations,
Title 5, Sections 42850-42854.
2.
Eligibility: With the exception of certain student classifications, eligible employees can participate in the 403(b) program,
including rehired annuitants (regardless of age). Please contact the campus Benefits Office for eligibility guidelines.
3.
Parties: The parties to this Agreement are the Board of Trustees of The California State University, hereinafter sometimes
referred to as the “CSU,” and you, hereinafter sometimes referred to as the “Employee.”
4.
Agreement: In consideration of the potential advantages to each, the CSU and you, the Employee, make this Agreement under
the terms provided. This Agreement shall be effective beginning with the salary warrant payable as specified on the 403(b)
Salary Reduction Request Form, in accordance with State Controller’s Office (SCO) processing guidelines.
5. Salary Reduction and 403(b) Investment:
A. Type of Salary Reduction Agreement. You can contribute to no more than two 403(b) companies at one time.
You may make changes at any time throughout the year, subject to any allocation change restrictions imposed by your current
company(ies).
Please note: If you wish only to change the allocation of your current contributions or existing fund balance(s)
among your current company’s funds, you must do that directly with the company. There is no need to complete this
form for an allocation change.
The CSU has contracts with companies that offer plans qualifying under the provision of Internal Revenue Code Section
403(b) and California Revenue and Taxation Code Section 17512 (although the CSU makes no warranty of such
qualification). These plans are either 403(b) tax sheltered annuities (TSA) or mutual fund custodial accounts. The CSU
assumes no responsibility for the financial security, investments or other operations of these plans.
From among these plans indicated on the 403(b) TSA Authorized List, you have selected the designated Company plan(s)
and the amount of funds as stated on the 403(b) Salary Reduction Request Form, which the CSU agrees to remit to the
designated Company plan(s)‚ on your behalf.
In handling these funds, the CSU acts as an employer, and not as a Trustee. The CSU assumes no responsibility for any
investment loss nor claim to any gain, based upon any delays in making the contributions agreed to herein. It shall be your
responsibility to notify the designated Company so that any necessary follow-up actions may be taken.
9 Change/cancel existing 403(b) salary reduction amount. Complete sections B, D and E on the 403(b) Salary
Reduction Request Form, if you want to change the amount or cancel your current salary reduction, and indicate
changes you wish to make.
9 New 403(b) Investment. Complete sections C, D and E on the 403(b) Salary Reduction Request Form to start
new deferral(s), or restart previously canceled reductions. Please note, if you are restarting previously canceled
reductions, please make certain that the TSA account is not closed.
B. Reduction. The CSU shall reduce each regular monthly installment of salary due you, the Employee, under the terms of your
appointment by the amount you request, beginning with the salary warrant as indicated in Section D of the 403(b) Salary
Reduction Request Form, if the request is submitted to the campus Benefits Representative in a timely manner. This
Agreement will not be effective for any salary made available prior to the date this Agreement is signed.
6. Minimum Reduction. At no time is a 403(b) salary reduction to be less than $15.00 per month.
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7. Reduction Change. This reduction shall continue to be made until such time as the Agreement is terminated by whichever of the
following events occurs first:
A. By termination of your employment, or
B. By either party giving 30-day advance written notice of termination to the other. Termination by such notice may only be made
effective on the first day of a pay period. Notice by you, the employee, shall be sent to the campus Benefits Office or to other
such office, as the Benefits Office shall require. Notice to you shall be sent to your home address or to other such address as
designated by you, or
C. By your filing a new Agreement with the CSU, or
D. By the CSU if the Company’s contract with the CSU is terminated. You may not continue having contributions made to a
terminated Company, but you may arrange to substitute another company which has a current contract with the CSU, or you
may terminate participation under the procedures in Section 7B.
8. Annuities Non-forfeitable. Any annuity purchased under Section 5 shall be non-forfeitable except for failure to pay future
premiums expressly required by the contract between you and the Company(ies).
9. Release of Earnings. You, your spouse, heirs, administrators, executors and representatives, hereby release all rights, present
and future, to receive in any form other than payments from the designated Company, the amount to be applied as designated in
Section 5.
10. Computations. You assume full responsibility for all computations and for the maintenance of all data required to carry out such
computations in connection with the salary reduction and demonstrating that such salary reduction complies with Internal Revenue
Code Section 403(b) and related sections and to corresponding provisions of the California Revenue and Taxation Code (see, for
example, Authority, Section 1) and regulations thereunder, including amendments which may be made to such codes or
regulations or both, subsequent to the date of this Agreement.
Internal Revenue Service Publications provide information on the maximum amounts, which may be contributed to the plan by
participating employees. In addition, there can be lower limits for those employees who also participate in the State Savings Plus
(401k) Plan. You may consult with your Company, its agents, or the Internal Revenue Service for advice on these matters. The
CSU has no responsibility for any advice given or computations made.
11. Proof of Computations. The CSU, at its discretion, may require proof that you have performed or have had performed all
required computations in connection with the salary reduction pursuant to Internal Revenue Code Section 403(b) and related
sections and regulations thereunder. Such computations may be required as evidence to support the amount of salary reduction.
Lacking such evidence, or if such evidence does not support the amount of salary reduction, the CSU has the authority to reduce
the amount of salary reduction.
By signing and dating the 403(b) Salary Request Form, you certify that all computations have been performed in connection with
the requested salary reduction pursuant to Internal Revenue Code Section 403(b) and related sections and regulations thereunder
and that you will maintain proof of such computations.
12. Participation in Other Plans. You can defer the annual maximum toward both a 403(b) account and a governmental 457 plan*
(administered by the Department of Administration Savings Plus Program). If, however, you contribute to both a 403(b) and a
401(k) plan in the same tax year, your 401(k) annual limit will be reduced by the amount you contribute to your 403(b) plan. You
cannot defer maximum contributions to both a 403(b) and a 401(k) during the same tax year.
13. Employee Releases The CSU From Any Damages. You assume full responsibility for the tax, processing, and investment
consequences which result from the salary reduction hereby agreed to, and hereby release the State of California, the members of
the Board of Trustees of the California State University, both individually and together acting as a board, their employees, agents,
and the successors of each of the foregoing, and any combination thereof, from any liability including, but not limited to, any
financial loss resulting from failure to carry out or inaccuracies in any of the computations referred to in Section 10, from selection
or performance of Company(ies) or of any particular plan, from incorrect evaluation of tax-deferred status, from processing delays
or errors, from discontinuance of present legislation effecting such benefits, and from incorrect advice you may have received or
may receive in the future from the CSU, the Company(ies), any of their employees or agents, or any other plan respecting the
plans and the benefits that may be received as a result of the salary reduction agreement hereby agreed upon.
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14. Company Status. You understand and agree that for the purposes of this Agreement, no Company is an agent or employee of
the State of California or of the CSU; and the State of California, the CSU and their employees are not agents of any Company.
15. Company Account Required. You understand and agree that this Agreement is between you and the CSU and does not
establish an account with the company(ies). You assume full responsibility for filing appropriate documentation to establish an
account with the designated company(ies). You shall provide proof of company-established account(s) to the Benefits Office at
the time this Agreement is presented.
If for any reason your account is not established at the Company(ies) you have designated, the Company(ies) will return the
money to the SCO/CSU for delivery to you via payroll. All returned money will be considered taxable income.
16. Irrevocable Commitments. This Agreement shall be legally binding and irrevocable with respect to salary amounts received
while the Agreement is in effect.
17. Processing Fee. The CSU reserves the right to assess you with a processing fee to cover the costs of administering the 403(b)
program, including the payroll deduction and investment transactions. You may contact the Benefits Office to determine the
current fee schedule, if any.
18. Effect of Agreement Execution. Execution of this Agreement by you, the Employee, shall constitute application by you to the
CSU pursuant to Education Code Section 89505 for purchase of a 403(b) plan contribution and reduction in salary under the terms
of this agreement.
The CSU and Employee agree to the foregoing terms of this Agreement.
Note to Employee: Record Your Actions from the 403(b) Salary Reduction Request Form below:
Change And/or Cancellation of Current TSA Investments
1)
TSA Company:
________________________________
2)
Deduction Code: ______________
TSA Company: ________________________________
Deduction Code: ______________
Agent’s Name
________________________________
Agent’s Name
________________________________
Telephone:
________________________________
Telephone:
________________________________
Change Requested:
CANCEL
NO CHANGE
Current Amount: $ _________
CHANGE AMOUNT
New Amount: $ _________
Date Request Submitted _____________
Change Requested:
CANCEL
NO CHANGE
Current Amount: $ _________
CHANGE AMOUNT
New Amount: $ _________
Date Request Submitted ______________
New TSA Investments
1)
TSA Company: ________________________________
Deduction Code: ______________
2)
TSA Company: _________________________________
Deduction Code: _______________
Agent’s Name
_____________________________
Agent’s Name
___________________________
Telephone:
______________________________
Telephone:
_________________________________
Amount to be deferred: $ ________
Date Request Submitted __________
Amount to be deferred: $ ________
Date Request Submitted ___________
*Some employee classifications are not eligible to enroll in a 457 Plan (administered by the Savings Plus Program). Refer to the “Getting Started In Savings
Plus” Brochure for additional information.
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