403(b)

403(b) SALARY REDUCTION AGREEMENT FORM

Please supply the information requested below.

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Read all agreements on this form before submitting.

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Fields having an asterisk notation are required.

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(SRA) For Tax Sheltered Annuities and Custodial Accounts

IMPORTANT NOTICE: Before You Sign, Read All Information on this form:

A Tax Sheltered Annuity (“TSA”) is an investment account that is set aside for your retirement (only), and is paid for with “pre-tax” dollars. A Custodial Account (“CA”) is the group or

individual custodial account or accounts, established for each Employee, by the Employer, or by each Employee individually, to hold assets of the Plan. Unless

utilizing the catch-up

provisions, your Maximum Allowable Contribution (“MAC”) cannot exceed $16,500 ($22,000 if age 50 or over). Both TSA & CA receive tax deferred treatment.

Part 1: Employee Information

Please check here if you have contributed to a 403(b) plan with another employer this calendar year. If so, please provide the

amount of the year-to-date contributions you have made to the other employer's plan:

and the name of the

other employer:

Social Security Number:

First Name:

MI:

Last Name:

Address:

City:

State:

Zip:

Date of Birth:

Part 2: Employer Information

Full Organization Name, City and State:

Date of Hire: (mm/dd/yyyy)

Part 3: Contribution Information

OPTION 1: Recurring Contributions

WARNING!!! Any new recurring contributions will supercede all current recurring contributions to your employer's 403(b) plan administered

by OMNI. If you are currently contributing to multiple service providers under your employer's 403(b) plan, please be sure to list all

contributions you wish to continue. Any active 403(b) contributions found in our records, but not listed below WILL BE DISCONTINUED.

Please withold funds from my pay for the following 403(b) contributions until further notice:

Plan Type

Service Provider

Account #

Effective Date

Amount Per Pay

Percent Per

Pay Period

403(b)

ROTH 403(b)

Your Annual Salary:

Number of Pay Periods Per Year:

403(b)

ROTH 403(b)

403(b)

ROTH 403(b)

403(b)

ROTH 403(b)

403(b)

ROTH 403(b)

Email address:

Phone:

If you have requested a percentage amount for any of the contributions above, please supply:

After this contribution, any 403(b)

recurring contributions to this

service provider should be:

403(b)

ROTH 403(b)

Plan Type

Service Provider

Account #

Effective Date

Amount

OPTION 2: One-Time Contributions (Elective Contributions Only)

DISCONTINUED

RESUMED

403(b)

ROTH 403(b)

DISCONTINUED

RESUMED

403(b)

ROTH 403(b)

DISCONTINUED

RESUMED

403(b)

ROTH 403(b)

DISCONTINUED

RESUMED

403(b)

ROTH 403(b)

DISCONTINUED

RESUMED

I do not wish to participate at this time.

I understand that I may participate in the future simply by filling out a new Salary Reduction

Agreement form.

OPTION 3: Participation Opt Out

Continued on next page...

Also, a contribution may be discontinued by listing it below with an amount of zero.

Please check here if you are NOT a full-time employee

403(b)

Part 4: Agreements and Acknowledgements

The above named Employee where applicable, agrees as follows:

1. To modify his/her salary reduction as indicated above.

2. That his/her Employer transfers the above stated funds on Employee’s behalf to OMNI for remittance to the selected Service Provider(s).

3. This SRA is legally binding and irrevocable with respect to amounts paid.

4. This SRA may be changed with respect to amounts not yet paid.

5. This SRA may be terminated at any time for amounts not yet paid or available, and that a termination request is permanent and remains in

effect until a new SRA is submitted.

6. (a) That OMNI does not choose the annuity contract or custodial account in which your contributions are invested.

(b) OMNI does not endorse any authorized Service Provider, nor is it responsible for any investments.

(c) OMNI makes no representation regarding the advisability, appropriateness, or tax consequences of the purchase of the TSA

and/or CA described herein.

(d) (i) OMNI shall not have any liability whatsoever for any and all losses suffered by Employee with regard to his/her selection of the

TSA and/or CA, its terms, the selection of any service provider, the financial condition, operation of or benefits provided by said

service provider, or his/her selection and purchase of shares by any service provider. Nothing herein shall affect the terms of

employment between Employer and Employee.

(ii) Employee acknowledges that Employer has made no representation to Employee regarding the advisability, appropriateness, or

tax consequences of the purchase of the annuity and/or custodial account described herein.

(iii) The Employer shall not have any liability for any and all losses suffered by an Employee with regard to the selection(s) of any

TSA and/or CA, any related terms and conditions, the selection of any service provider, the financial condition, operation of or

benefits provided by any service provider or the selection and purchase of shares by any service provider.

7. To be responsible for setting up and signing the legal documents necessary to establish a TSA or CA.

8. To be responsible for naming a death beneficiary under their TSA or CA. This is normally done at the time the contract or account is

established. Beneficiary designations should be reviewed periodically.

9. When provided all required information in a timely manner, OMNI is responsible for determining that salary reductions do not exceed the

allowable contribution limits under applicable law, and will complete MAC calculations as required by law.

10. To contact OMNI and complete the appropriate OMNI forms for any requests for distributions, loans, hardship withdrawals, account exchanges

plan-to-plan transfers or rollover contributions. Processing fees for the foregoing transactions may apply.

11. This SRA is subject to the terms of the Services Agreement between OMNI and Employer, and to the Information Sharing Agreement

between OMNI and the Service Providers, copies of which may be obtained from Employer.

12. This agreement supercedes all prior salary reduction agreements and shall automatically terminate if Employee’s employment is terminated.

Part 5: Employee Signature (Mandatory)

I certify that I have read this complete agreement and that my salary reductions do not exceed contribution limits as determined by applicable

law. I understand my responsibilities as an Employee under this Program, and I request that Employer take the action specified in this agreement.

I understand that all rights under the TSA or CA established by me under the Plan are enforceable solely by my beneficiary, my authorized

representative or me.

Employee Signature

Date

Part 6: Acknowledgement and Representation of Sales Agent/Representative (If Applicable)

I agree to comply with all pertinent written directives regarding the solicitation of Employee. A calculation of maximum allowance will be provided

annually for Employee contributing more than $16,500 ($22,000 if over 50) or utilizing the “catch-up provisions”. Furthermore, my employer

(name)__________________________________________________ agrees to indemnify and hold harmless the Employer, any individual

member of the governing board and the Employee participating in the 403(b) Program against any claims based on an error in the MAC I provided,

except where the error is based upon erroneous information provided by Employer or Employee. Additionally, I will notify OMNI regarding any

distributions or loans to participants.

Sales Agent/Representative Name:

Phone:

Address:

Signature:

Date:

Please return this agreement to The OMNI Group, unless otherwise advised by your employer:

The OMNI Group

Watertower Office Park • 1099 Jay Street, Building F • Rochester, NY 14611

Toll Free: (877) 544-OMNI ® • Fax: (585) 672-6194

Please visit our website at

www.omni403b.com

recording, or any information storage and retrieval system, without permission in writing from The OMNI Group. Requests for permission to reproduce

content should be directed to the Legal Department at The OMNI Group, Legal@omni403b.com.

and OMNI ® are registered service marks of OMNI Financial Group, Inc. DBA The OMNI Group

Part 7: Employer Acknowledgement (If Applicable)

Employer Name & Title:

Employer Signature:

Date:

Salary:

# of TSA/CA Pay Periods:

Effective Payroll Date: