Kan. Admin. Regs. § 91-29-12 - Contract form; reduction of salary for tax sheltered annuity

KSDE FORM 01 01 100




Contract to Reduce Salary for Tax Sheltered

Annuity Purposes

TO: Chief Fiscal Officer


State School Location

Effective with respect to amounts earned on or after the first day of the pay period beginning on _____,

(day and month)

19__, which date is subsequent to the execution of this contract, and pursuant to the provisions of Section 403(b), United State Internal Revenue Code of 1954, as amended, and as authorized by 1976 S.B. 870, the State Board of Education is hereby authorized and directed to reduce my future compensation to purchase for me a non-forfeitable annuity or annuities as hereinafter described.

Please place an "X" in the appropriate box or boxes

(Box A is not applicable to non-TIAA/SCREF Participants)

Under the required 5%/5% retirement plan for employees the State Board of Education shall:

1. Reduce my gross compensation by 5% applicable each payday.
2. Pay an identical amount to provide retirement benefits as described in Subsections (1)(a), (1)(b), (1)(c), and (4) of K.S.A. 74-4925; and
3. Apply said sums to the payment of deposits for a retirement annuity contract selected by me in accordance with the terms of the required 5%/5% retirement program and issued by TIAA/SCREF.
B. Under the voluntary tax-sheltered annuity program the State Board of Education shall:
1. Reduce my gross compensation by _____% per month for each payday.
2. Apply said sum to deposits for a non-forfeitable retirement annuity contract selected by me and issued by (only one company can be listed)

It is further agreed and understood that the State Board of Education assumes no liability or responsibility either for the income tax aspects of these annuity programs or for the annuity policy terms and provisions.

This agreement shall be legally binding and irrevocable as to both of the parties hereto while employment continues; provided, however, either party may change or terminate this agreement as of the end of any payroll period, so that it will not apply to compensation not yet earned, by giving at least thirty (30) days written notice of the date of said change or termination; and provided, further, that no more than one agreement for such compensation reduction may be made within any calendar year.

This agreement shall remain in force for the duration of employment, except as changed or terminated within the allowable provision of this agreement hereinabove stated.

In witness whereof the parties have hereunto set their hands and seals this _____ day of _____, 19_____.



(Chief Fiscal Officer) (Date) (Employee's Full Name--print or type)


(State School) (Signature of Employee) (Date)

(To be completed by agency)



Agency NAME Vol.TSA Voluntary TSA


No. Dept. Soc. Sec. No. Last First Initial Eff. Date Co. Code%


Kan. Admin. Regs. § 91-29-12
Authorized by K.S.A. 76-11a03; effective, E-78-6, Jan. 20, 1977; amended, E-78-11, March 24, 1977; effective May 1, 1978.

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