West Contra Costa Unified School District

1108 Bissell Ave. Richmond, CA 94801

(510) 231-1155 Fax: (510) 236-8158

AGREEMENT FOR PURCHASE

EMPLOYEE ID: ______

□ ROTH 403(b) (Met Life only)BOX: ______

□ 403(b) OR 457(b) TAX DEFERRED CODE: ______

NAME______(Employee), and West Contra Costa Unified School District of Contra Costa County, California, through it’s duly elected governing board, hereinafter called the “DISTRICT”, mutually understand and agree that for the purpose of taking advantage of the “deferred compensation” provisions of section 403(b) or 457(b) of the IRS Code, the employee authorizes the Employer on behalf of:

(Annuity Firm)______to:

Contribute$______per pay period effective ____/____/______(mm, dd, yyyy).

CONDITIONS AND TERMS:

  1. The salary reduction specified above shall continue unchanged, unless the Employee gives 30 days notification for cancellation or change to the Employer.
  1. The Employee will be permitted to make one contract change each calendar year with the Employer. The Employee may terminate the agreement at any time.
  1. Any existing shelter contributions or annuity will continue until terminated in writing by the Employee.
  1. Employee acknowledges that Employer has made no representation to Employee regarding the advisability, appropriateness, or tax consequences of the purchase of the annuity.
  1. This agreement shall be for contracted employees who are paid on the last day of the month and will automatically terminate if the Employee either takes a leave of absence or terminates their employment. A new application must be submitted upon return from leave or if employment is re-instated.
  1. In the event that the Employee’s salary for any month, available for this purpose, is insufficient to allow this reduction, the District reserves the right to pay the Employee such salary with out making any reduction under this agreement.
  1. Employee is responsible for maintaining compliance with IRS regulations.

DISCLAIMER:

The DISTRICT and the County of Contra Costa shall have no liability whatsoever for any and all losses suffered by Employee with regard to his/her selection of this annuity and/or custodial account, its terms, the selection of the insurance company or regulated investment company, the financial condition, operation of or benefits provided by said insurance company or regulated investment company, or his/her selection and purchase of shares of regulated investment companies.

This document is due no later than the 10th of the month.

Contact Payroll for December, February and June deadlines.

* Employee must establish an account directly with the annuity firm. Enter contract number below or attach proof of said account before application will be processed.

SIGNATURE: ______DATE: ______PHONE: (_____)______

AGENTS NAME: ______PHONE: (_____)______

* EMPLOYEE COMPANY CONTRACT OR ACCOUNT # ______

Available TSA Companies for WCCUSD
403(b) Pre Tax
AIG Valic Life
American Express / Ameriprise
American Fidelity Assurance
American Fund - Capital Guard
Americo Financial Life and annuity Ins. Co. (NOT AFLAC)
AXA Equitable Life
CalSTRS
Connecticut Mutual Variable (Mass Mutual)
Fidelity Investments (Distributor)
Franklin Trust (Templeton)
General American Life
Great American Life Ins (GALIC)
Horace Mann Life
Industrial-Alliance Pacific Life Ins.
ING Retirement Plan -ReliaStar Life Ins.
Jackson National Life
Life Ins Co. of the Southwest
Lincoln National Life
Metropolitan Life Resources 403b-Pre Tax
Midland National Life
National Health Insurance
New York Life Ins.
North American Company for Life & Health
Oppenheimer Investors
Paul Revere Variable
Plan Member Service
Security Benefit Life
T. Rowe Price
Transamerica Life
U S A A Life Ins.
Waddell & Reed
403b ROTH After Tax
Metropolitan Life Resources
457 plan
Tax Deferred Services - 457 Plan - (Life Insurance of the South West)
WCCUSD Deferred Com/National - 457 Plan