"Delaware 403(B) Plan Sick vacation Deferral Form" - Delaware

Delaware 403(B) Plan Sick vacation Deferral Form is a legal document that was released by the Delaware Office of the State Treasurer - a government authority operating within Delaware.

Form Details:

  • Released on November 5, 2018;
  • The latest edition currently provided by the Delaware Office of the State Treasurer;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Delaware Office of the State Treasurer.

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Download "Delaware 403(B) Plan Sick vacation Deferral Form" - Delaware

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Please fax completed form to the Office of the State Treasurer at (302) 677-7031
Sick\Vacation Deferral
State of Delaware 403(b) Plan
(Use this form only for contributions to the 403(b) Plan)
Notice to employee:
If you are not currently enrolled in the 403(b) plan, contact Voya Financial at (800) 584-6001 or
www.delawaredefer.com
to enroll
before retirement your date.
The Office of State Treasurer must receive this signed form no later than the end of the month prior to the month you will receive your
payout check (the check includes your accumulated sick and vacation pay).
Last Name (Please Print)
First Name
M.I.
DOB
Home Address - Street
Employee ID#
City / Town
State
Zip
Home Phone
Agency or School District
Name of Payroll Representative
Phone
Date of Retirement
Date of Payout Check:
or Separation:
Sick Leave Payout:
Vacation Leave Payout
Additional Salary:
Total Gross Pay:
Please specify your deduction amount. For 2019, the maximum amount for the calendar year is $19,000. In addition, if you are at
least 50 years of age by the end of 2019, you can defer an additional $6,000. Please indicate whether the amount to be deferred is a pre-
tax or after tax “Roth” deduction. Please note that amount deferred are before State and Federal taxes but not before social security
taxes.
Pre-tax
Roth
Deduction amount: $__________________________________
Signature of Employee:
Date:
_______________
Please verify your payout information with your Payroll Representative, sign and date the form, and fax it to the attention of
the Office of the State Treasurer at (302) 677-7031.
Last updated 11.5.18
Please fax completed form to the Office of the State Treasurer at (302) 677-7031
Sick\Vacation Deferral
State of Delaware 403(b) Plan
(Use this form only for contributions to the 403(b) Plan)
Notice to employee:
If you are not currently enrolled in the 403(b) plan, contact Voya Financial at (800) 584-6001 or
www.delawaredefer.com
to enroll
before retirement your date.
The Office of State Treasurer must receive this signed form no later than the end of the month prior to the month you will receive your
payout check (the check includes your accumulated sick and vacation pay).
Last Name (Please Print)
First Name
M.I.
DOB
Home Address - Street
Employee ID#
City / Town
State
Zip
Home Phone
Agency or School District
Name of Payroll Representative
Phone
Date of Retirement
Date of Payout Check:
or Separation:
Sick Leave Payout:
Vacation Leave Payout
Additional Salary:
Total Gross Pay:
Please specify your deduction amount. For 2019, the maximum amount for the calendar year is $19,000. In addition, if you are at
least 50 years of age by the end of 2019, you can defer an additional $6,000. Please indicate whether the amount to be deferred is a pre-
tax or after tax “Roth” deduction. Please note that amount deferred are before State and Federal taxes but not before social security
taxes.
Pre-tax
Roth
Deduction amount: $__________________________________
Signature of Employee:
Date:
_______________
Please verify your payout information with your Payroll Representative, sign and date the form, and fax it to the attention of
the Office of the State Treasurer at (302) 677-7031.
Last updated 11.5.18