University of Houston System
Retirement Program Participation Form / Salary Reduction Agreement
(Optional Retirement Program, Tax Deferred Annuity (403b), Roth 403b and 457 Texa$aver)

Employee Information:

Name: ________________________________________________    Empl ID:___________________________
             (Last, First, MI)

Department: ___________________________________________    Campus: ___________________________

Telephone #: ___________________________________________   Campus Mail ID _____________________

Participation Acknowledgement

Effective the _______ day of _____________________, 20_____, the University of Houston is hereby authorized and directed to reduce my compensation to purchase for me a non-transferable and non-forfeitable retirement account or tax deferred annuity as hereinafter described.

•	Optional Retirement Program – Which will reduce my gross compensation by the amount specified by the State of Texas to provide retirement benefits; and apply said funds as payment for a retirement annuity contract selected by me and approved by the University of Houston System, in accordance with the terms of the Optional Retirement Program.  The University of Houston System reserves the right to amend these amounts should future legislation make it necessary to do so.   I acknowledge that the State’s contribution for the first full year (or fractional part thereof) of participation will be refunded to the state by the ORP carrier in the event I do not begin a second year of employment with the State of Texas in an ORP eligible position in accordance with the provisions of the Optional Retirement Statute.

•	Tax Deferred Annuity (403b) – Will reduce my gross compensation by the amount shown below and apply said sum (Pre-Tax) toward the purchase of a 403 b agreement in my name. 

•	Roth 403 b – Will reduce my gross compensation by the amount shown below and apply said sum (Post Tax) toward the purchase of a 403b agreement in my name. 

•	457 DC (Texa$aver) – Will reduce my gross compensation by the amount shown below and apply said sum (pre-tax) toward the purchase defer compensation agreement in my name.

Contract Criteria:

Name of Carrier: _____________________________________________________________________

Agent Name ___________________________________  Telephone # __________________________

 Initial Authorization        Amended Authorization      Termination of Salary Agreement      Carrier Change

Reduction Amount:  Monthly:                                              or Bi-Weekly: 

Is Age Related or Retirement Date Catch-up provision being used?     	 Yes       No

Is 402(g) Service Date Catch-up provision being used?		 Yes       No	

Authorization:
This agreement shall continue for the duration of my employment; provided that a change, modification, or termination of the agreement may be made only as prescribed by law and the University of Houston System rules governing the Optional Retirement Program and the Tax Deferred Annuity Program.  It is agreed and understood that the University of Houston System assumes no liability or responsibility either for the Income tax aspects of either retirement program or annuity program or for retirement or annuity policy terms and provisions.

I hereby acknowledge that I have read and understand the above information.  I further understand that the University of Houston System assumes no responsibility for the financial performance of any company nor does it guarantee the company’s current and/or future financial standing.

Employee Signature _____________________________________________________  		Date __________________________________

Human Resources Approval _______________________________________________		Date __________________________________