St.FrancisSchool District

403(b) Salary Reduction Agreement

PLEASE PRINT WITH BLACK INK • SIGN AND DATE

Participant Information

Social Security no. (last 4 digits) XXX-XX-Employer name

NameDate of hire ______/______/

LastFirstMiddle

AddressDate of Birth______/______/

Daytime phone (____)

CityStateZip

Evening phone (____)

□Check here if new address

Select Reason for Salary Reduction Agreement

□ New enrollment□ Change□ Terminate contributions

Participant Contribution Information (this agreement replaces prior agreements)

VENDOR:

Regular 403(b) (before tax) Roth 403(b)(after tax) TOTAL SRA AMOUNT
$ + $ =$
per-month contributionper-month contribution combined Regular 403(b) and
Roth 403(b) contributions
Number of pay periods per calendar year

* * *

VENDOR:

Regular 403(b) (before tax) Roth 403(b)(after tax) TOTAL SRA AMOUNT
$ + $ =$
per-month contributionper-month contribution combined Regular 403(b) and
Roth 403(b) contributions
Number of pay periods per calendar year

THIS FORM HAS TWO PAGES—YOU MUST ALSO REVIEW, COMPLETE AND SIGN THE REVERSESIDE

Participant Authorization

I hereby authorize and direct the St.FrancisSchool District (the “District”) to withhold the salary reduction amounts indicated on the reverse from my compensation. The salary reduction amounts indicated on the reverse will only be processed if there is sufficient salary to cover the request.

This Agreement is legally binding upon me and may be terminated by me only by giving notice of termination in the payroll period preceding the payroll period in which the termination is to be effective.

Plan Limitations

For 2013 and 2014, you can make maximum pretax payroll contributions of up to $17,500 if you are under age 50, and up to $23,000 if you are age 50 or older.

Participant Execution

By the execution of this Agreement, I represent that:

(1) I have made an independent determination as to my desire to make these salary deferrals;

(2)I have assessed the risk associated with such investment(s) and have determined, with such professional advice as I deemed necessary, that the product offered by the Vendor is suitable to me;

(3)The District has no responsibility to evaluate or to apprise me, now or in the future, as to the performance, status or otherwise as to the operation or viability of any product offered by the Vendor or alternative investments; and

(4)I agree to be bound by all the terms and conditions of the District’s 403(b) Plan.

I release the District from any and all claims that I may assert in the event that the product which I have chosen under this Agreement shall fail to qualify for preferential tax treatment under Code section 403(b). I understand that the District assumes no responsibility, actual or implied, with respect to the calculation of the contribution or the limits on such contributions.

Signature of ParticipantDate

District Approval

The District will remit the amount of the salary reduction to the Vendors described above for investment into Participant’s 403(b) account.

Name Agreement effective date

Signature Date