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Step 1 of 3: Supply Information | Step 2 of 3: Confirm Entries | Step 3 of 3: Submission Confirmation
  • Please supply the information requested below.
  • Read all agreements on this form before submitting.
  • Fields having a red asterisk notation are required.

403(b) Salary Reduction Agreement (SRA) For Tax Sheltered Annuities and Custodial Accounts

IMPORTANT NOTICE: Before You Sign, Read All Information on this form:
A Tax Sheltered Annuity (“TSA”) is an investment account that is set aside for your retirement (only), and is paid for with “pre-tax” dollars. A Custodial Account (“CA”) is the group or individual custodial account or accounts, established for each Employee, by the Employer, or by each Employee individually, to hold assets of the Plan. Unless utilizing the catch-up provisions, your Maximum Allowable Contribution (“MAC”) cannot exceed $19000 ($25000 if age 50 or over) for 2019. Both TSA & CA receive tax deferred treatment.

Please supply the information requested below. All fields marked with a red asterisk are required.
Part 1: Employer Information
*Employer State: *Employer Name: *Date of Hire: (MM/DD/YYYY)

Part 2: Employee Information
Please select your Employer's State and Name before continuing.
Part 3: Contribution Information
Please select your Employer's State and Name before continuing.
Part 4: Agreements and Acknowledgements

The above named Employee where applicable, agrees as follows:
  1. To modify his/her salary reduction(s) as indicated above.
  2. That his/her Employer transfers the above stated funds on Employee’s behalf to OMNI® for remittance to the selected Service Provider(s).
  3. This SRA is legally binding and irrevocable with respect to amounts paid.
  4. This SRA may be changed with respect to amounts not yet paid.
  5. This SRA may be terminated at any time for amounts not yet paid or available, and that a termination request is permanent and remains in effect until a new SRA is submitted.
    1. That OMNI® does not choose the annuity contract or custodial account in which your contributions are invested.
    2. OMNI® does not endorse any authorized Service Provider, nor is it responsible for any investments.
    3. OMNI® makes no representation regarding the advisability, appropriateness, or tax consequences of the purchase of the TSA and/or CA described herein.
      1. OMNI® shall not have any liability whatsoever for any and all losses suffered by Employee with regard to his/her selection of the TSA and/or CA, its terms, the selection of any service provider, the financial condition, operation of or benefits provided by said service provider, or his/her selection and purchase of shares by any service provider. Nothing herein shall affect the terms of employment between Employer and Employee.
      2. Employee acknowledges that Employer has made no representation to Employee regarding the advisability, appropriateness, or tax consequences of the purchase of the annuity and/or custodial account described herein.
      3. The Employer shall not have any liability for any and all losses suffered by an Employee with regard to the selection(s) of any TSA and/or CA, any related terms and conditions, the selection of any service provider, the financial condition, operation of or benefits provided by any service provider or the selection and purchase of shares by any service provider.
  6. To be responsible for setting up and signing the legal documents necessary to establish a TSA or CA.
  7. To be responsible for naming a death beneficiary under their TSA or CA. This is normally done at the time the contract or account is established. Beneficiary designations should be reviewed periodically.
  8. When provided all required information in a timely manner, OMNI® is responsible for determining that salary reductions do not exceed the allowable contribution limits under applicable law, and will complete MAC calculations as required by law.
  9. To contact OMNI® and complete the appropriate OMNI® forms for any requests for distributions, loans, hardship withdrawals, account exchanges plan-to-plan transfers or rollover contributions. Processing fees for the foregoing transactions may apply.
  10. This SRA is subject to the terms of the Services Agreement between OMNI® and Employer, and to the Information Sharing Agreement between OMNI® and the Service Providers, copies of which may be obtained from Employer.
  11. This agreement supersedes all prior salary reduction agreements and shall automatically terminate if Employee’s employment is terminated.

©2019 All rights reserved. No part of this SRA maybe reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the OMNI® Group. Requests for permission to reproduce content should be directed to the Legal Department at The OMNI® Group,

By clicking the button below labeled "Continue", I hereby confirm that the information on this form is correct and complete to the best of my knowledge. I certify that I have read this complete agreement and that my requested salary reduction(s), if in excess of my base limit, represent(s) my wish to utilize any catch-up provisions for which I may be eligible. I further certify that I will notify OMNI in the event I begin contributing to another 403(b), 401(k) or 401(a) plan. I understand my responsibilities as an Employee under this Program, and I request that Employer take the action specified in this agreement. I understand that all rights under the TSA or CA established by me under the Plan are enforceable solely by my beneficiary, my authorized representative or me.


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