Common use of Salary Deferral Agreement Clause in Contracts

Salary Deferral Agreement. E-Mail Address Mo Day Year ❑ Female ❑ Male ❑ Married ❑ Unmarried Date of Birth This Agreement shall apply to all compensation paid from the effective date specified, until cancelled, superceded, or the employee ceases to be an eligible employee. This Agreement supercedes all previous agreements. I understand that I may change the percentage of compensation or dollar amount contributed to the Plan only when and as allowed under the terms of the Plan. I also understand that it is my responsibility to comply with the Internal Revenue Code deferral limits. Payroll Information Specify one of the following: ❑ New Enrollment ❑ Restart ❑ Increase Payroll Deduction ❑ Decrease Payroll Deduction ❑ Stop Deductions Specify the following: ❑ I elect to contribute % or $ (per pay period) of my compensation as before-tax contributions to the Governmental 457(b) Deferred Compensation Plan until such time as I revoke or amend my election. Payroll Effective Date: Date of Hire: Mo Day Year Mo Day Year Deferral agreements must be entered into prior to the first day of the month that the deferral will be made. Required Signatures - I have completed, understand and agree to the terms of this Agreement and authorize the payroll deduction as indicated on this form. Deferral agreements must be entered into prior to the first day of the month that the deferral will be made. I also understand that if I am increasing or decreasing my payroll deductions, the new deferral amount will take effect on the first pay period after the first of the month in which the change was made. If I am stopping payroll deductions, all existing deferrals will be cancelled. Participant Signature Date Authorized Plan Administrator/Trustee Signature Date Participant forward to Plan Administrator/Trustee Plan Administrator forward to Service Provider at: Great-West Retirement Services Xxx Xxxxxxxx Xxxxxx, Xxxxx 0000 Xxxxxxx, XX 00000 Phone #: 0-000-000-0000 Fax #: 0-000-000-0000 Web site: xxx.xxxxxxxxx.xxx ][GP22][/154071370

Salary Deferral Agreement. E-Mail Address Mo Day (a) In general. Each Plan Year, a Participant may elect to enter into a written Salary Deferral Agreement with the Employer which shall be applicable to a specified number of payroll periods within the Plan Year ❑ Female ❑ Male ❑ Married ❑ Unmarried Date following the date of Birth This such Salary Deferral Agreement. The terms of any such Salary Deferral Agreement shall apply provide that the Participant agrees to all compensation paid accept a reduction in salary from the effective date specified, until cancelled, supercededEmployer equal to a stated percentage of his Compensation per payroll period, or a fixed dollar amount, or some combination thereof, not to exceed either: (1) the employee ceases to be an eligible employeeamount specified in the Adoption Agreement for a Salary Deferral Agreement for the Plan Year, or (2) the dollar limit contained in Code section 402(g) in effect at the beginning of the calendar year. This Agreement supercedes A Participant’s Elective Deferrals for a calendar year under the Plan, plus the Participant’s elective contributions under all previous agreements. I understand that I may change other plans, contracts and arrangements of the percentage of compensation or dollar amount contributed Employer, shall not exceed the limit imposed by Code section 402(g) for such calendar year, except to the Plan only when extent permitted under Section 3.01(d) and as allowed under Code section 414(v), if applicable. In consideration of such Salary Deferral Agreement, the terms Employer shall make a Salary Deferral Contribution to the Participant’s Salary Deferral Account (and, if applicable, the Participant’s Salary Deferral Catch-up Contribution Account) and a Xxxx 401(k) Contribution to the Participant’s Xxxx 401(k) Account (and, if applicable, the Participant’s Xxxx 401(k) Catch-up Contribution Account) on behalf of the Plan. I also understand that it is my responsibility to comply with the Internal Revenue Code deferral limits. Payroll Information Specify one of the following: ❑ New Enrollment ❑ Restart ❑ Increase Payroll Deduction ❑ Decrease Payroll Deduction ❑ Stop Deductions Specify the following: ❑ I elect to contribute % or $ (per pay period) of my compensation as before-tax contributions Participant for such Plan Year in an amount equal to the Governmental 457(b) Deferred total amount by which the Participant’s Compensation from the Employer was reduced during the Plan until such time as I revoke or amend my election. Payroll Effective Date: Date of Hire: Mo Day Year Mo Day Year Deferral agreements must be entered into prior pursuant to the first day of the month that the deferral will be made. Required Signatures - I have completed, understand and agree to the terms of this Agreement and authorize the payroll deduction as indicated on this form. Participant’s Salary Deferral agreements must be entered into prior to the first day of the month that the deferral will be made. I also understand that if I am increasing or decreasing my payroll deductions, the new deferral amount will take effect on the first pay period after the first of the month in which the change was made. If I am stopping payroll deductions, all existing deferrals will be cancelled. Participant Signature Date Authorized Plan Administrator/Trustee Signature Date Participant forward to Plan Administrator/Trustee Plan Administrator forward to Service Provider at: Great-West Retirement Services Xxx Xxxxxxxx Xxxxxx, Xxxxx 0000 Xxxxxxx, XX 00000 Phone #: 0-000-000-0000 Fax #: 0-000-000-0000 Web site: xxx.xxxxxxxxx.xxx ][GP22][/154071370Agreement.

Salary Deferral Agreement. E-Mail Address Mo Day Year ❑ Female ❑ Male Date of Birth ❑ Married ❑ Unmarried Date of Birth Do you have a retirement savings plan with a previous employer or an IRA? ❑ Yes or ❑ No This Agreement shall apply to all compensation paid from the effective date specified, until cancelled, superceded, or the employee ceases to be an eligible employee. This Agreement supercedes all previous agreements. I understand that I may change the percentage of compensation or dollar amount contributed to the Plan only when and as allowed under the terms of the Plan. I also understand that it is my responsibility to comply with the Internal Revenue Code deferral limits. Payroll Information Specify one of the following: ❑ New Enrollment ❑ Restart Payroll Deductions ❑ Increase Payroll Deduction Deductions ❑ Decrease Payroll Deduction Deductions ❑ Stop Payroll Deductions Specify the following: ❑ I elect to contribute % or $ (per pay period) of my compensation as before-tax contributions to the Governmental 457(b) Deferred Compensation Plan until such time as I revoke or amend my election. Note: The total of your before-tax and Xxxx deferrals cannot exceed $16,500.00. Your before-tax and Xxxx deferrals must be specified consistently (both as a percent or both as a dollar amount). If I am 50 years of age or older and I am eligible for a catch-up contribution, I understand I may exceed this total. $17,000.00. ❑ I elect to contribute $ (per pay period) of my compensation after-tax as a designated Xxxx contribution to the Governmental 457(b) Deferred Compensation Plan until such time as I revoke or amend my election. Note: The total of your before-tax and Xxxx deferrals cannot exceed $17,500.00. Your before-tax and Xxxx deferrals must be specified consistently (as a dollar amount). If I am 50 years of age or older and I am eligible for a catch-up contribution, I understand I may exceed this total. Payroll Effective Date: Date of Hire: Mo Day Year Mo Day Year Deferral agreements must be entered into prior to the first day of the month that the deferral will be made. Required Signatures - Payroll Information Payroll Center Name Payroll Center Number Division Name Division Number Your Consent and Signature I have completed, understand and agree to the terms of this Agreement and authorize the payroll deduction as indicated on this form. Deferral agreements must be entered into prior to the first day of the month that the deferral will be made. I also understand that if I am increasing or decreasing my payroll deductions, the new deferral amount will take effect on the first pay period after the first of the month in which the change was made. If I am stopping payroll deductions, all existing deferrals will be cancelled. Participant Signature Date Participant forward to Plan Administrator/Trustee GWRS FSALDF 11/19/12 Page 1 of 2 DACA/Manual (Contrib update) ][A03:041012 ][GP22/286340533 Last Name First Name MI Social Security Number Authorized Signature(s) Great-West Retirement Services® PO Box 173764 Denver, CO 80217-3764 Express Address: 0000 X. Xxxxxxx Xxxx, Xxxxxxxxx Xxxxxxx, XX 00000 Phone #: 0-000-000-0000 Authorized Plan Administrator/Trustee Signature Date Participant forward to Plan Administrator/Trustee Plan Administrator forward to Service Provider at: Great-West Retirement Services Xxx Xxxxxxxx 0000 Xxxx Xxxxxx, Xxxxx 0000 XxxxxxxMadison, XX 00000 WI 53718 Phone #: 0-000-000-0000 Fax #: 0-000-000-0000 E-mail: xxxxxxxxxx@xxxx.xxx Web site: xxx.xxxxxxxxx.xxx xxx.xxx000.xxx Great-West FinancialSM refers to products and services provided by Great-West Life & Annuity Insurance Company; Great-West Life & Annuity of New York, White Plains, New York; their subsidiaries and affiliates. Great-West Retirement Services® refers to products and services provided by Great-West Life & Annuity Insurance Company, FASCore, LLC (FASCore Administrators, LLC in California), Great-West Life & Annuity Insurance Company of New York, White Plains, New York, and their subsidiaries and affiliates. Great-West Life & Annuity Insurance Company is not licensed to conduct business in New York. Insurance products and related services are sold in New York by its subsidiary, Great-West Life & Annuity Insurance Company of New York. Other products and services may be sold in New York by FASCore, LLC. GWRS FSALDF 11/19/12 Page 2 of 2 DACA/Manual (Contrib update) ][GP22][/154071370A03:041012

Salary Deferral Agreement. E-Mail Address Mo Day Year ❑ Female ❑ Male ❑ Married ❑ Unmarried Date of Birth This Agreement shall apply to all compensation paid from the effective date specified, until cancelled, superceded, or the employee ceases to be an eligible employee. This Agreement supercedes all previous agreements. I understand that I may change the percentage of compensation or dollar amount contributed to the Plan only when and as allowed under the terms of the Plan. I also understand that it is my responsibility to comply with the Internal Revenue Code deferral limits. Payroll Information Specify one of the following: ❑ New Enrollment ❑ Restart ❑ Increase Payroll Deduction ❑ Decrease Payroll Deduction ❑ Stop Deductions Specify the following: ❑ I elect to contribute % or $ (per pay period) of my compensation as before-tax contributions to the Governmental 457(b) Deferred Compensation Plan until such time as I revoke or amend my election. Payroll Effective Date: Date of Hire: Mo Day Year Mo Day Year Deferral agreements must be entered into prior to the first day of the month that the deferral will be made. Required Signatures - Division Name Division Number Your Consent and Signature I have completed, understand and agree to the terms of this Agreement and authorize the payroll deduction as indicated on this form. Deferral agreements must be entered into prior to the first day of the month that the deferral will be made. I also understand that if I am increasing or decreasing my payroll deductions, the new deferral amount will take effect on the first pay period after the first of the month in which the change was made. If I am stopping payroll deductions, all existing deferrals will be cancelled. Participant Signature Date Participant forward to Plan Administrator/Trustee Authorized Signature(s) Authorized Plan Administrator/Trustee Signature Date Participant forward to Plan Administrator/Trustee Plan Administrator forward to Service Provider at: Great-West Retirement Services Xxx Xxxxxxxx XxxxxxXxxx County 0000 Xxxxxxx Xxx, 0xx Xxxxx 0000 XxxxxxxXxxxxxxxxxx, XX 00000 00000-0000 Phone #: 0-000-000-0000 Fax #: 0-000-000-0000 Web site: xxx.xxxxxxxxx.xxx xxx.xxxx000.xxx ][GP22][/154071370XXXX][/202161113

Salary Deferral Agreement. E-Mail Address Mo Day Year ❑ Female ❑ Male ❑ Married ❑ Unmarried Date of Birth Do you have a retirement savings plan with a previous employer or an IRA? ❑ Yes or ❑ No This Agreement shall apply to all compensation paid from the effective date specified, until cancelled, superceded, or the employee ceases to be an eligible employee. This Agreement supercedes all previous agreements. I understand that I may change the percentage of compensation or dollar amount contributed to the Plan only when and as allowed under the terms of the Plan. I also understand that it is my responsibility to comply with the Internal Revenue Code deferral limits. Payroll Information Specify one of the following: ❑ New Enrollment ❑ Restart Payroll Deductions ❑ Increase Payroll Deduction Deductions ❑ Decrease Payroll Deduction Deductions ❑ Stop Payroll Deductions Specify the following: ❑ I elect to contribute % or $ (per pay period) of my compensation as before-tax contributions to the Governmental 457(b) Deferred Compensation Plan until such time as I revoke or amend my election. Payroll Effective ❑ I elect to contribute $ (per pay period) of my compensation after-tax as a designated Xxxx contribution to the Governmental 457(b) Deferred Compensation Plan until such time as I revoke or amend my election. Warrant Distribution Date: Date of Hire: Mo Day Year Mo Day Year Deferral agreements must be entered into prior to the first day of the month that the deferral will be made. Required Signatures - Your Consent and Signature I have completed, understand and agree to the terms of this Agreement and authorize the payroll deduction as indicated on this form. Deferral agreements must be entered into prior to the first day of the month that the deferral will be made. I also understand that if I am increasing or decreasing my payroll deductions, the new deferral amount will take effect on the first pay period after the first of the month in which the change was made. If I am stopping payroll deductions, all existing deferrals will be cancelled. Participant Signature Date Authorized Plan Administrator/Trustee Signature Date Great-West Retirement Services® PO Box 173764 Denver, CO 80217-3764 Participant forward to Plan Administrator/Trustee Plan Administrator forward to Service Provider at: GreatEmpower Retirement PO Box 173764 Denver, CO 80217-West Retirement Services Xxx Xxxxxxxx Xxxxxx3764 Express Address: 0000 X. Xxxxxxx Xxxx, Xxxxx 0000 Xxxxxxxxx Xxxxxxx, XX 00000 Phone #: 0-000-000-0000 *UHDW-:HVW )LQDQFLDO60 UHIHUV WR SURGXFWV DQG VHUYLFHV SURYLGHG E\ *UHDW-:HVW /LIH & $QQXLW\ ,QVXUDQFH &RPSDQ\; *UHDW-:HVW /LIH & $QQXLW\ RI 1HZ <RUN, :KLWH 3ODLQV, 1HZ <RUN; WKHLU VXEVLGLDULHV DQG DIILOLDWHV. *UHDW-:HVW 5HWLUHPHQW 6HUYLFHVŠ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ore securities, when offered, are offered through GWFS Equities, Inc. and/or other broker dealers. GWFS Equities, Inc., Member FINRA/SIPC, is a wholly owned subsidiary of Great-West Life & Annuity Insurance Company Empower Retirement refers to the products and services offered in the retirement markets by Great-West Life & Annuity Insurance Company (GWL&A), Corporate Headquarters: Greenwood Village, CO; Great-West Life & Annuity Insurance Company of New York, Home Office: White Plains, NY; and their subsidiaries and affiliates. All trademarks, logos, service marks, and design elements used are owned by their respective owners and are used by permission. Fax #: 0-000-000-0000 Web site: xxx.xxxxxxxxx.xxx ][GP22][/154071370FSALDF 07/15/15 98214-01 LDOM - MANUAL(SR 15995523) LDOM - Manual Page 1 of 1 FSALDF 04/11/15 98214-01