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Aurora Public Schools Tax-Sheltered Annuity Plan
Contribution Authorization/Change Form For 2017
Complete all information and return this form to Benefits/Human Resources – ESC 4
|Your ID# | |
| |
|Name | |Home Phone |( ) |
|Last First MI | |
| |
|Address | |
| |
|City | |State | |ZIP Code | |
| |
|Work Location | |Work Phone |( ) |
| |
|Effective date of change | |
| |Month/Year |
| |
To ensure your change is processed in the month you have requested, this form must be received by the 15th. Please place an “X” on the appropriate line below:
| |SUSPEND my 403(b) Plan Deductions |
| | |
| |CHANGE MONTHLY DEDUCTION: I request a 403(b) plan monthly contribution of _____________ % (whole percentage) or $ _____________ to |
| |be deducted from my compensation. This amount must be no more than 100% of my includible compensation not to exceed $18,000 in |
| |calendar year 2017 ($24,000 if over 50).[1] I have not taken a hardship withdrawal or qualified reservist distribution in the last |
| |6 months. |
| | |
I understand that this Contribution Authorization/Change Form shall apply to compensation paid to me including:
(a) compensation earned while an employee; and
(b) effective January 1, 2011,
(i) compensation paid to me which is received up to two and one-half (2 ½) months after my severance from employment or the end of the Plan Year that includes the date of my severance from employment, if it is a payment that would have been paid to me while I continued in employment with Aurora Public Schools;
(ii) any unused accrued bona fide sick, vacation or other leave, which is paid to me if paid no later than two and one-half (2 ½) months after my severance from employment or the end of the Plan Year that includes the date of my severance from employment, if it is a payment that would have been paid to me while I continued in employment with Aurora Public Schools; and
(iii) payment by Aurora Public Schools to me when I am not currently working for Aurora Public Schools because of qualified military service, but limited to the amount I would have received if I were working for Aurora Public Schools.
This Contribution Authorization/Change Form will continue indefinitely unless I instruct otherwise.
|Signature | |Date | |
| |
|Name of TSA Vendor | | | |
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[1] If you have completed 15 years of service with APS, please consult your vendor and attach a certification as to the amount you are allowed to contribute.
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