Salary Deferral Agreement

This form is for individuals who have a workplace SIMPLE IRA plan. This form allows an employee to update their Simple IRA contribution amount.

Full Name

e.g.) John Doe

Email

Name of Employer

I. Salary Deferral Election. Subject to the requirements of my SIMPLE IRA plan, I authorize the following amount to be withheld from my pay for each pay period and contributed to my SIMPLE IRA.

Please withhold the following percentage (%) amount from each pay period.

Please withhold the following dollar ($) amount from each pay period.

Maximum Salary Deferral.

Date Salary Deferral Begins.

Print Name

e.g.) John Doe

Signature