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.

About the plan participant:
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
· E-mail: info@stillriverretire.com