~Dual Comp Staff Provider Onboarding Binder 06.26.20

FOR PAYROLL USE ONLY : Enroll in Fidelity, if applicable

2020 Retirement Voluntary Contributions Worksheet

Employee Name Effective Date If Dual Comp status please pay close attention to the IRS limits below as it is your responsibility to make sure you do not exceed the limits if you are contributing to both employer ’ s plan(s). New Plan Change in Amount

From Fidelity toTIAA From TIAA to Fidelity

1. 403(b) Voluntary Pretax and/or Roth 403(b) After Tax employee contributions ( Total annual maximum of $19,500 or $26,000 if over age 50 – annual maximum is an aggregate of the 403(b) Pretax and Roth After tax) $ or % per MONTH to my 403(b) - Pretax



% per MONTH to my Roth 403(b) - After Tax

No changes to current 403(b) contributions

Stop current contribution

457(b) Voluntary Pretax Employee Contribution $ or


% per MONTH to my 457(b) - Pretax

( Annual Maximum of $19,500 or $26,000 if over age 50)

No changes to current 457(b) contributions

Stop current contribution

Please note contribution amounts are subject to IRS Guidelines and Regulations. Additionally, if you do not select investment options within the plan, you will automatically be invested in the default funds for each Investment Provider (Fidelity Freedom Fund or TIAA Lifecycle Fund) which are based upon normal expected retirement age. For the 403(b) plan, Roth 403(b) plan and 457(b) plan, you have the right to terminate this agreement by giving written notice on this form of your desire to do so, or it shall be considered terminated upon termination of your employment. Termination by written notice shall be effective as of the beginning of the next pay period following the pay period during which such notice was delivered.

Employee Signature


Employer Signature


Required Actions 4

Revised 1/ 31 /20 20

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