Warning: If any of the following unusual conditions apply to your situation, additional information may be needed. Contact
The 403(b) Help Line for help if: you control the employer offering this plan or control any other employer offering a Defined
Contribution plan; participation in this 403(b) plan is 100% mandatory or subject to a one time election; you make after-tax contributions to the plan, or you have made
recent hardship withdrawals; or life insurance is being used to fund the plan.
Name:
Employer has adopted age 50 catchup provision in the 403(b) plan document.
If true then please provide date of birth (mm/dd/yyyy):
About your job:
Which best describes the employer offering the 403(b) plan? (select one):
Public school system
Hospital
Home health srvc agency
Health and Welfare Srvc Agency
Church or
church organization
College / University /
Private school
Other not-for-profit organization
Your total compensation from this employer for the full tax year: $
As of the end of the tax year, how many full years have you worked here?
(Give only partial credit for years you worked part-time or only part of the year.) This information not required if less than 15 years.
If you worked less than full-time for the full year: (otherwise skip the next two questions)
What percent of full-time did you work? %
How much was your actual compensation for this year, plus your compensation from
enough prior pay periods to equal one full-time, full year of work? $
Still River Retirement Planning Software, Inc.
· 69 Lancaster County Rd.,
Harvard, MA 01451
· (978) 456-7971
· Fax: (978) 456-7972
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403(b) - 2007