HTML Preview Payroll Deduction Agreement Form page number 1.
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Email: retirement@agfinancial.org • Web: www.agfinancial.org/retirement
PAYROLL DEDUCTION AGREEMENT FORM
This agreement is between you and your employer. DO NOT SEND TO AG FINANCIAL SOLUTIONS.
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Employee Information
Please use full legal name
Full Legal Name ___________________________________________________________________
Last First Middle Initial
This is a: New agreement Change to my existing agreement
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Employer Information
Name of Employer _________________________________________________________________
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Agreement
This Agreement is made between you and Employer named above. This Agreement will change all payroll
deduction contributions to the employee’s account(s). If an option in section A is left blank, it will be
assumed that the election amount is zero. This agreement will remain in effect as long as your employment
continues or until another agreement is exercised.
Your employer may not offer some deferral/deduction options. Check with your employer to see what options
are available. See descriptions of each type of deferral/deduction on the back of this form.
A. I elect to defer eligible compensation (e.g., wages or salaries) as follows beginning on ___/___/______.
Pre-tax 403(b) elective deferral $ _________ or _________ % per pay period
Roth 403(b) after-tax deferrals $ _________ or _________ % per pay period
After-tax deferrals $ _________ or _________ % per pay period
AGLF Demand Certificate # _________ in the amount of $ ________ or _______ % per pay period
(Existing AGLF Demand Certificates only; for new investment information, call 1.866.453.7143.)
B. If I have selected the Roth 403(b) after-tax deferral, I understand that qualified distributions for the Roth 403(b) deferral
accounts are different from Roth IRA accounts.
C. I understand, upon written notice, that I may change or terminate my payroll deductions at any time within the
guidelines established by my employer.
D. I understand that I am responsible for determining that the amount of my salary reduction does not exceed the limits for
403(b) contributions.
E. I understand that the responsibility for choosing the deferral type and investment elections is my own and not that of my
employer, MBA, or any other person or group. I understand that my own tax and investment professionals are the best
people to advise me in their respective areas of expertise.
F. I understand that elective deferrals and employer contributions are not available for distribution except when I have a
distributable event as defined by the Internal Revenue Service and MBA Plan rules.
The Employee and the Employer hereby agree to this Payroll Deduction Agreement Form:
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Signature of Employee Date
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Signature of Employer Date