Contribution Information. Prior to your policy year under this Account-Based Offerings Administrative Services Agreement, and then for each subsequent renewal date, you must provide to Blue Cross and Blue Shield the following information: each covered employee’s annual FSA, TFS, and PFS contributions; and your contributions for each covered employee’s FSA, TFS, PFS, and HRA. If any of this information changes during your policy year, you must promptly inform Blue Cross and Blue Shield of those changes.
Contribution Information. True and full information regarding the amount of cash and a description and statement of the agreed value of any other property or services contributed by each Member and which each Member has agreed to contribute in the future. Any Member (personally or through an authorized representative) may, for any purpose reasonably related to such Member’s Interest, inspect and copy (at its own cost and expense) the books and records of the Company at all reasonable business hours.
Contribution Information. Please see the Xxxxxxxxx ESA Custodial Agreement and Disclosure Statement for general contribution and rollover guidelines. The type of contribution being made to this Xxxxxxxxx ESA must be designated in this section. Computershare Trust Company advises that you (a) check with your tax/or financial advisor before establishing a Xxxxxxxxx ESA, and (b) effect any rollover contributions from existing Xxxxxxxxx ESAs on a cash-only basis.
Contribution Information. This CESA will be funded with the following type of contribution (select one): Annual CESA contribution for Tax Year $ Tax Year $ Transfer from another CESA Rollover from another CESA Other Explain:
Contribution Information. (Select all that apply & complete amounts in part 3) **All deductions are taken on a post-tax basis** New salary reduction and/or district match amount Effective Date:* Change salary reduction amount and/or district match amount Discontinue TSA salary reduction with the following Service Provider(s): Employee’s deductions (this tax year) to all 403b plans or all 457 plans are expected to exceed $22,500/year. Employee is over age 50 and planning to deduct an additional $7,500 in the current calendar year Employee’s Birth Date: (Maximum payroll deduction amounts are limited to the basic limit plus additional allowances for over age 50) ▪ Requests are accepted any time from September 1st – May 31st. Requests received over the summer will be held until September 1st. ▪ Completed Salary Reduction Agreement forms must be received prior to the current payroll or they will be held until the following payroll. ▪ All deductions are taken post tax
Contribution Information. (Select all that apply) • New salary reduction Please deduct the amount of $ per pay for pays. • Change salary reduction This is notification to change the amount of my TSA salary reduction from $ to $ per pay. • Change service provider This is notification to change my Service Provider (indicate amounts in Part 3) from to . • Discontinue salary reduction Please discontinue my TSA salary reduction with the following Service Provider: . Employee is utilizing catch-up provisions/special elections. Yes No If yes, please attach Maximum Annual Contribution Worksheet which can be found at xxxx://xxxxxxx.xxx/sag_forms.html Implementation date: Salary reduction instructions shall be implemented in accordance with the Hartland Consolidated Schools 403(b) Plan documents. Employee is responsible for establishing an account with the Service Provider before any amounts are transmitted to the Service Provider by the Employer. Part 3. Service Provider Deduction Per Pay Service Provider EMPLOYER: HARTLAND CONSOLIDATED SCHOOLS By: Dated: EMPLOYEE: Signature SERVICE PROVIDER: Dated: Dated: Signature Please Print Agent’s Name By signing above, Employee acknowledges receipt of attached Part 4, Additional Terms of Agreement.
Contribution Information. A. The amount of the salary reduction shall be $ (whole dollars only) per pay period for the amounts paid on or after (date).
Contribution Information. (Select only those that apply) ❑ I do not wish to participate at this time. I understand that I may participate in the TSA program at any time in the future simply by contacting an approved district TSA vendor. (Please sign and date on reverse side in Part 4 and return to Business Office.) ❑ No change. (I’m a current TSA participant: continue my existing salary reduction and Service Provider.) ❑ Initiate New Salary Reduction. I have already opened a new TSA; my account # is Please deduct $ per pay. ❑ Change Salary Reduction. This is notification to change the amount of my TSA salary reduction from $ per pay to $ per pay ❑ Change Service Provider. This is notification to change my Service Provider (indicate amounts in Part 2) from to . My new account # is . ❑ Discontinue Salary Reduction. Please discontinue my TSA salary reduction with the following Service Provider: . Implementation Date: Salary reduction instructions shall be implemented in accordance with Employer’s administrative schedule. Part 2. Service Provider (Investment Company): (This section must be completed if you are participating in the Plan) Investment Company Amount Per Pay Period
Contribution Information. (Select all that apply): Effective Date: Pay period beginning Initiate new salary reduction: deduct the amount of $ per pay period for $ per year Change salary reduction This is notification to change the amount of my 403(b) salary reductions from $ per pay to $ per pay for total $ per year Change or Discontinue Provider From to Implement Age 50 catch-up: Date of birth The IRS requires coordination of contributions to this plan with contributions to plans of other employers in which you may participate. Please respond to the two questions below.
