File:  GBC – E1

 

 

 

DEFERRED WAGE PAYMENT ELECTION FORM

 

            This is to notify the Buena Vista City school division that I have elected, beginning with the 2008-09 school year, to have the salary for the period I actually perform services paid out over a 12-month period.

 

            In the event that a separation from service occurs before the end of the 12-month payment period, I will be entitled to an additional payment for the amount I have actually earned from the beginning of the 12-month pay period until the date of my separation from service, but which has not yet been paid.  This additional payment will be included in my final paycheck.  For this purpose, “separation from service” has the same meaning as that term is defined in section 1.409A-1(h) of the Treasury Regulations.

 

            This notice is irrevocable for any particular school year, and may not be changed or withdrawn after the beginning of the school year in which I am working.  This notice will be effective for the 2008-09 school year and all following school years unless I change my election.  If I choose not to have my salary deferred in any future school year and be paid only during the period that I actually perform services, I will so notify the Buena Vista City school division in writing prior to beginning work for that school year.

 

            This notice will have no effect if it is not submitted to the division prior to the time I begin working for the 2008-09 school year.

 

 

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Signature                                                                                                            Date

 

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Printed Name

 

 

 

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