Colleen C. Davis
State Treasurer

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Sick and Vacation Pay Deferral Form


The Office of State Treasurer must receive this 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).


Notice to employee:

  • If you are not currently enrolled in the 457(b) or 403(b) plan, contact Voya Financial at (800) 584-6001 or to enroll before retirement your date.
  • Education employees (DOE, DTCC, DSU, or schools) may be able to contribute to both plans in the same calendar year.
I have discussed the following with my HR representative.
Personal Information


Employer Information


Separation Information

Deduction Information

Please specify your deduction amount. For 2021, the maximum amount for the calendar year is $19,500. In addition, if you are at least 50 years of age by the end of 2021, you can defer an additional $6,500. Please indicate whether the amount to be deferred is a pretax or after tax “Roth” deduction. Please note that the pre-tax amounts deferred are before State and Federal taxes, but not before social security taxes.

Tip: Keep payroll taxes in mind when determining your deduction. To ensure that your deduction can be processed, leave yourself a threshold for these taxes by inputting a deduction amount that is 92% of the available funds.

Pre-Tax  Roth

I hereby authorize that I am the individual indicated above.
Please verify your payout information with your Payroll Representative.