THE LYNDE AND HARRY BRADLEY FOUNDATION, INC.

403(b) Program Salary Reduction Agreement

Action Requested:	□ New	□ Change	□ Terminate

1.	Employee Name and Address

Name (Last, First, Middle Initial)

Address

City, State, Zip Code	Daytime Phone Number

2.	Employee Number:	Social Security Number:

3.	□ The Employer is hereby authorized to reduce my salary each pay period by $ or by %.

□ The Employer is hereby authorized to terminate my current 403(b) Salary Reduction Agreement of $ or %.

4.	My 403(b) Salary Reduction amount is to be sent to:

(Attach additional mailing or account information.)

5.	Effective Date: The employer is requested to initiate/terminate/change my salary as indicated above as of the pay period beginning:

As of payroll period beginning on the date indicated in item #5, with respect to services to be rendered by the Employee hereafter, the employee authorizes the Employer to reduce the Employee's salary in the amount or by the percentage indicated in item #3. Contributions are subject to annual limits and reductions will be suspended each year when the limit is reached. This contribution is made only to the extent there are wages available after satisfying any other salary reduction or deduction request on file. The Employer will send the salary reduction amount to the company or companies you have chosen in item #4, to apply such amount to your 403(b) program account, provided that you have supplied all of that company's required paperwork to us. A notice of termination of, initiation of, or a change in, salary reduction may be effective no earlier than the Payroll Period that begins after the notice is received by the Payroll Department. Contributions are subject to an annual dollar limit and will be suspended when that limit is reached.

This agreement is binding and irrevocable with respect to amount earned while this Agreement is in effect, and any termination of this agreement shall be effective only with respect to amounts not yet earned as of the effective date of such termination.

The Employee understands and agrees that the Employer is not responsible to determine the amount which the IRS will allow the Employee to defer, and that it is the Employee's responsibility to verify this amount. The 403(b) program is completely separate from any other Employer Retirement Plan.

Employee Signature:	Date:

Received for the Employer:	Date: