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Salary Reduction Agreement For The Lane ESD Selected Vendors 403(b) Plan

Blank Salary Reduction Form

If you prefer not to complete the fillable SRA Form on this page, and click the ‘Generate BLANK SRA Form’ button below:

Fillable Salary Reduction Agreement

By entering your information into the fillable form below, and then clicking the 'Generate Printable SRA Form' button, you will generate a printable Salary Reduction Form which should be printed out, signed by you, and then submitted to Lane ESD with documentation that you have established an account with each selected Vendor:

Your Information

Your Name, Address, and Contact information is required.

  • Name
  • Street Address
  • Apt, Suite, or Unit (if applicable)
  • City
  • State
  • Zip
  • Telephone (home or mobile)
  • Email
  • Social Security Number
  • Agent Name and Telephone (If Applicable)

Effective Dates

Implementation: This Salary Reduction Agreement (the 'Agreement') supersedes any previous Salary Reduction Agreement for the person named below (the "Employee") under the Selected Vendors 403(b) Tax Sheltered Annuity Plan (the "Plan") offered by Lane Education Service District (the "Employer"), also known as Lane ESD. The salary reduction specified in this agreement will begin with the first paycheck on or after the "Effective Begin Date" specified below, provided this form is received by the Employer before the Payroll cutoff date for that paycheck. This Agreement will remain effective until a new Agreement is submitted.

  • Begin Date
Employee's Details:

Select the Appropriate Type of Agreement Below:

  • Replace/Override a Previous 403(b) Plan Salary Reduction Agreement
  • Start/Initiate a Very First (new) 403(b) Plan Salary Reduction Agreement
  • Cancel/Discontinue an Existing 403(b) Plan Salary Reduction Agreement (Cancels Deductions to All Vendors)

Distribution Among Vendors

If selecting a new Vendor, you MUST include documentation that an account has been established with the new Vendor that is linked to Lane ESD. Vendor accounts linked to former employers may not be used for contributions at Lane ESD. Lane ESD allows you to contribute to a maximum of 3 different vendors. If Replacing/Overriding a Previous Salary Reduction Agreement or Starting/Initiating a New Salary Reduction Agreement, you must select at least one Vendor.

$ Traditional Dollars per Paycheck
$ Roth Dollars per Paycheck

$ Traditional Dollars per Paycheck
$ Roth Dollars per Paycheck

$ Traditional Dollars per Paycheck
$ Roth Dollars per Paycheck

  • Account Number at FIRST Vendor †REQUIRED IF you specified a Vendor above in the FIRST Vendor drop-down list.
  • Account Number at SECOND Vendor †REQUIRED IF you specified a Vendor above in the SECOND Vendor drop-down list.

Clicking the button below will Generate a printable PDF form populated with the information entered above. You must still sign, date, and submit the form to the address indicated at the bottom of page one along with documentation of your open account:


Page Last Modified: 8/26/2021 4:42:11 PM