Office of Human Resources

Rendleman Hall, Room 3210

Edwardsville, IL 62026

618-650-2190

Salary Deferral Authorization Form

I,	(print name)	, elect to have salary deferral
begin with my next academic year contract. I request that my 9 (10, or 11) month contract be paid over 12 months instead. I understand that my pay will be made over an annualized pay schedule and this election will remain in effect for each of the following academic years until I revoke this authorization for a future academic year.

Because the IRS prohibits changes made within the academic year, I am aware that my election is irrevocable during that 12 month period. To be paid without deferral for a future academic year, I must complete a Salary Deferral Revocation Form and submit it to Payroll prior to the first day of the new contract. Should there be separation from service (as defined by the IRS - termination, retirement, or death during the year), a lump sum payment will be issued for my deferred pay along with my final pay, pending employer approval.

This Salary Deferral Authorization Form is only effective if submitted to Payroll prior to the first day of my contract for the new academic year, as required by the IRS. Salaried 9, 10, or 11-month contracted employees may participate in this program. There is no fee for salary deferral. I understand that salary deferral will begin with next year’s academic contract and that my current pay will continue to be paid according to my contract.

Term Academic Employees: If my term contract is not renewed for the next academic year, my defer pay balance will be paid out in a lump sum along with my final paycheck at the end of the term contract. ______

Initial

All information below must be completed. Payroll will send a confirmation e-mail to verify the request has been received.
Signature
Date
Banner ID No.
E-mail
If you have questions please refer to Salary Deferral Guideline, the FAQ’s or contact Payroll at 650-2190.
DO NOT WRITE BELOW THIS LINE
Date Received by Payroll: _____________________________________________________________

Confirmed by E-mail on: ______________________________________________________________

Payroll Entered on: ________________________ Initials: __________________________________

4/2012

Offices of Human Resources

rajohns

2012-04-20

Joyree Chura

SIUE