Authorization For Salary Reduction Regarding Election To Participate In A Supplemental Annuity Contract Form

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THE UNIVERSITY CORPORATION, SAN FRANCISCO STATE.
P.O. Box 320160
San Francisco, CA 94132-0160
Reset
AUTHORIZATION FOR SALARY REDUCTION
REGARDING ELECTION TO PARTICIPATE IN A
SUPPLEMENTAL ANNUITY CONTRACT
__________________
(Date)
I, _______________________________ hereby request that the employment arrangement
between us be modified to substitute the purchase of a supplemental annuity by you, in lieu of a
portion of the compensation otherwise payable directly to me, so that I may obtain the benefit of
Section 17512 of the California Revenue and Taxation Code. For such purpose I authorize you
to:
1. Reduce my cash compensation under said employment arrangement by the sum of
$_____________ per pay period, effective ____________________.
2. Apply the said sum to the purchase of a Tax-Deferred Annuity contract issued by
____________________ in which I shall be named as owner.
I release all rights, present or future, to receive payment in any other form of said sum except,
(1) the right of my estate upon my death while in your employment, or (2) the right personally,
upon termination of this agreement by me, to receive all or any part of the amount herein specific
for which I have already rendered services but which has not then been applied to the payment of
annuity premiums. I understand that amounts already paid for premiums may be withdrawn only
according to the terms of my annuity. Only one change, after initiation, in the above amount will
be permitted each calendar year.
______________________________________
(Signature)
------------------------------------------------------------------------------------------------------------------
Receipt of your request for modification of our employment arrangements are hereby
acknowledged and its terms are accepted this ____________ date of ________________.
San Francisco State University Foundation, Inc.
Effective Date ______________________
By ______________________________________

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