(SRA) For Tax Sheltered Annuities and Custodial Accounts
■ Please supply the information requested below.
■ Read all agreements on this form before submitting.
■ Fields having an asterisk notation are required.
IMPORTANT NOTICE: Before You Sign, Read All Information on this form:
A Tax Sheltered Annuity (“TSA”) is an investment account that is set aside for your retirement (only), and is paid for with “pre-tax” dollars. A Custodial Account (“CA”) is the group or
individual custodial account or accounts, established for each Employee, by the Employer, or by each Employee individually, to hold assets of the Plan. Unless utilizing the catch-up
provisions, your Maximum Allowable Contribution (“MAC”) cannot exceed $17,500 ($23,000 if age 50 or over). Both TSA & CA receive tax deferred treatment.
Part 1: Employee Information
Please check here if you have contributed to a 457 plan with another employer this calendar year. If so, please provide the
amount of the year-to-date contributions you have made to the other employer's plan: $
and the name of the
other employer:
* Social Security Number:
* First Name:
* Last Name:
* City:
* Date of Birth:
* Phone:
*Email address:
Part 2: Employer Information
* Full Organization Name, City and State:
* Date of Hire: (mm/dd/yyyy)
Part 3: Contribution Information
OPTION 1: Recurring Contributions
WARNING!!! Any new recurring contributions will supersede all current recurring contributions to your employer's 457 plan administered
by OMNI. If you are currently contributing to multiple service providers under your employer's 457 plan, please be sure to list all
contributions you wish to continue. Any active 457 contributions found in our records, but not listed below WILL BE DISCONTINUED.
If you simply wish to discontinue a contribution, fill in an amount of zero.
Please withhold funds from my pay for the following 457 contributions until further notice:
Plan Type
Service Provider
ROTH 457
ROTH 457
ROTH 457
ROTH 457
Account #
Effective Date
Amount Per Pay
Percent Per
Pay Period
If you have requested a percentage amount for any of the contributions above, please supply:
Your Annual Salary:
Number of Pay Periods Per Year:
Please check here if you are NOT a full-time employee
OPTION 2: One-Time Contributions (Elective Contributions Only)
Service Provider
Plan Type
Account #
Effective Date
After this contribution, any 457
recurring contributions to this
service provider should be:
ROTH 457
ROTH 457
ROTH 457
ROTH 457
Please check here if you are NOT a full-time employee
OPTION 3: Participation Opt Out
I do not wish to participate at this time. I understand that I may participate in the future by filling out a new Salary Reduction
Agreement form.
© 2014 The OMNI Group | 457 Salary Reduction Agreement, Effective 01/01/14, Page One of Two
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Part 4: Agreements and Acknowledgements
The above named Employee where applicable, agrees as follows:
1. To modify his/her salary reduction as indicated above.
2. That his/her Employer transfers the above stated funds on Employee’s behalf to OMNI for remittance to the selected Service Provider(s).
3. This SRA is legally binding and irrevocable with respect to amounts paid.
4. This SRA may be changed with respect to amounts not yet paid.
5. This SRA may be terminated at any time for amounts not yet paid or available, and that a termination request is permanent and remains in
effect until a new SRA is submitted.
6. (a) That Omni does not choose the annuity contract or custodial account in which your contributions are invested.
(b) Omni does not endorse any authorized Service Provider, nor is it responsible for any investments.
(c) Omni makes no representation regarding the advisability, appropriateness, or tax consequences of the purchase of the TSA
and/or CA described herein.
(d) (i) Omni shall not have any liability whatsoever for any and all losses suffered by Employee with regard to his/her selection of the
TSA and/or CA, its terms, the selection of any service provider, the financial condition, operation of or benefits provided by said
service provider, or his/her selection and purchase of shares by any service provider. Nothing herein shall affect the terms of
employment between Employer and Employee.
(ii) Employee acknowledges that Employer has made no representation to Employee regarding the advisability, appropriateness,
or tax consequences of the purchase of the annuity and/or custodial account described herein.
(iii) The Employer shall not have any liability for any and all losses suffered by an Employee with regard to the selection(s) of any
TSA and/or CA, any related terms and conditions, the selection of any service provider, the financial condition, operation of or
benefits provided by any service provider or the selection and purchase of shares by any service provider..
7. To be responsible for setting up and signing the legal documents necessary to establish a TSA or CA.
8. To be responsible for naming a death beneficiary under their TSA or CA. This is normally done at the time the contract or account is
established. Beneficiary designations should be reviewed periodically.
9. When provided all required information in a timely manner, Omni is responsible for determining that salary reductions do not exceed the
allowable contribution limits under applicable law, and will complete MAC calculations as required by law.
10. To contact Omni to start the process on any requests for loans, hardship withdrawals, account exchanges or plan-to-plan transfers.
11. This SRA is subject to the terms of the Services Agreement between Omni and Employer, and to the Information Sharing Agreement
between Omni and the Service Providers, copies of which may be obtained from Employer.
12. This agreement supersedes all prior salary reduction agreements and shall automatically terminate if Employee’s employment is terminated.
Part 5: Employee Signature (Mandatory)
I certify that I have read this complete agreement and that my requested salary reduction(s), if in excess of my base limit, represent(s) my wish to utilize any catch-up
provisions for which I may be eligible. I further certify that my salary reductions do not exceed contribution limits as determined by applicable law. I understand my
responsibilities as an Employee under this Program, and I request that Employer take the action specified in this agreement. I understand that all rights under the
TSA or CA established by me under the Plan are enforceable solely by my beneficiary, my authorized representative or me.
Employee Signature:
Part 6: Acknowledgement and Representation of Sales Agent/Representative (If Applicable)
I agree to comply with all pertinent written directives regarding the solicitation of Employee. A calculation of maximum allowance will be provided
annually for Employee contributing more than $17,500 ($23,000 if over 50) or utilizing the “catch-up provisions”. Furthermore, my employer
(name)__________________________________________________ agrees to indemnify and hold harmless the Employer, any individual
member of the governing board and the Employee participating in the 457 Program against any claims based on an error in the MAC I provided,
except where the error is based upon erroneous information provided by Employer or Employee. Additionally, I will notify OMNI regarding any
distributions or loans to participants.
Sales Agent/Representative Name:
Part 7: Employer Acknowledgement (If Applicable)
# of TSA/CA Pay Periods:
Effective Payroll Date:
Employer Name & Title:
Employer Signature:
Please return this agreement to The Omni Group, unless otherwise advised by your Employer:
The OMNI Group
Water Tower Park • 1099 Jay Street, Building F • Rochester, NY 14611
Toll Free: (877) 544-OMNI ® • Fax: (585) 672-6194
Please visit our website at www.omni403b.com
© 2014 All rights reserved. No part of this SRA may be reproduced or transmitted in any form or by any means, electronic or mechanical, including
photocopy, recording, or any information storage and retrieval system, without permission in writing from the Omni Group. Requests for permission to
reproduce content should be directed to [email protected]
and OMNI ® are registered service marks of Omni Financial Group, Inc. d/b/aThe Omni Group
© 2014 The OMNI Group | 457 Salary Reduction Agreement, Effective 01/01/14, Page Two of Two