Laurel County Board of Education 403(B) Plan

LaurelCounty Board of Education 403(b) Plan

Salary Deduction Agreement:This form must be completed and returned to Human Resources

Employer InformationContact Person:

Laurel Co. Board of EducationWanda Goodin

718 North Main Street Phone(606) 862-4600

London, KY40741 Fax(606) 862-4601

Employee Information

Name of Employee ______School ______

Social Security No. ______Date of Birth ______

Street Address ______

City ______State ______Zip ______

Mailing Address if Different ______

Daytime Phone ______Evening Phone______

AgreementLaurel County Board of Education (Employer) affirms that it is duly qualified as an organization described in Section 403(b)(1)( a) of the Internal Revenue Code of 1986, as amended(the “Code).The Employee named above

andthe Employer agree as follows:

1. The Compensation of the Employee shall be reduced as of the payroll period beginning ______

by the amount of $______per pay period to be contributed on a PreTax basis to the

employee’s 403(b) account held in trust by ______(Vendor).

Compensation shall mean the Employee’s cash compensation as an employee for services rendered to the Employer.

2. TheEmployer will forward the amount of such salary reduction for the Employee’s account to the Vendor.

3. This Agreement is legally binding on the undersigned Employee and Employer and is irrevocable with respect to

Compensation earned by such Employee while this Agreement is in effect.

4. This Agreement shall continue indefinitely until it is terminated; however, it may be amended with regard to reduction of

future Compensation by execution of a new written agreement by the Employee and the Employer or it’s representative.

5. In no event shall the combination of the aforesaid contributions exceed the limits provided be Sections 402(g) and 415 of the

Internal Revenue Code The Employee agrees to promptly notify the Employer in the event that these limits are affected by any

other plans maintained outside of this Employer or if he/she reaches any of the foregoing limits. The Employer reserves the

right to automatically reduce the amount of the Employee’s contribution if it is determined that these deductions will exceed

these limits.

6. This agreement is not a contract of employment between the parties hereto, and no provision hereof shall restrict the right of

the Employer to discharge the Employee or the right of the Employee to terminate his/her own employment.

7. All of the provisions of the Agreement are subject to the terms of the Laurel County Board of Education 403(b) Plan and

Vendor Custodial or Contract Agreement. Such Agreement is hereby incorporated by reference in this Agreement.

Signature The parties hereto have signed this Agreement as of (Date) ______.

______

Employee Signature Authorized Signature of Employer Representative