402 South Kentucky Ave., Suite 500, Lakeland, FL 33801
866.873.4240 ♦ Fax 863.688.4466 ♦ www.midamerica.biz

457 Retirement Savings Plan
Questions? Call our Service Center at 1-866-873-4240

 
Salary Reduction Agreement

Use this form to set up or change contributions to your 457 Account. Please type or print your information and fax to (863) 688-4466.
Employee Data – ALL FIELDS REQUIRED	
Employer Name:	
Name:	Social Security #:	
Address:	City/State/Zip:	
Daytime Phone #:	Date of Birth:	
Evening Phone #:	Date of Hire:	
Email Address:	# of Salary Reductions:	

Contribution Specifications

Complete this section to set up or change contributions to your 457 Account. Please note that the contribution amount may not exceed the maximum allowable limits as determined by the Internal Revenue Code. Review your Plan Highlights for the availability of Age 50 Catch-up Contributions. Click to view the Maximum Amount Contributable (MAC) limits for the current tax year.

Start new payroll deductions (Account must be established under your current employer’s plan prior to submitting SRA, fill in Account Number below).
Increase existing payroll deductions.	Decrease existing payroll deductions.
One-time payroll deduction then stop deductions.	One-time payroll deduction then revert to existing deductions. Change investment providers.  Stop contribution to		and start contributions to 	. Please stop my contributions to 		.
Make changes effective with payroll date 	.
You are responsible for establishing any annuity contract or custodial account with the Investment Provider(s) indicated below prior to submitting your Salary Reduction Agreement. Please provide your account # to avoid delay in processing your changes.

	Investment Provider(s)	Account #	Annual Salary Reduction	Salary Reduction Per Pay Period	
1.			$	$	
2.			$	$	
3.			$	$	
4.			$	$	
Total deduction each pay period $ 	
After the initial SRA is submitted and approved by MidAmerica, subsequent changes can be made online at: https://fe2.midamerica.biz/login.aspx.

Approval Signature

•	457 deferral changes will be effective with the payroll in the month following when this Salary Reduction Agreement is submitted.
•	This Salary Reduction Agreement is irrevocable with respect to amounts earned while it is in effect and applies only to amounts earned after the agreement becomes effective.
•	This Salary Reduction Agreement will continue until amended or terminated. This agreement shall automatically terminate with severance from employment.
•	The Employee agrees that the Employer shall have no liability whatsoever for any loss suffered by the Employee with regard to his/her selection of an investment provider, or the solvency of the operation of, or benefits provided by, said investment provider.

Signature of Employee	Date (Please note: Above date must be within last 90 days to be valid)

457SRA_NoRoth_Dollar	Rev. 06.26.2015