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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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