Finance

Download Payroll Deduction Agreement (PDF)

Fitness Club Membership, Payroll Deduction Agreement 

Purpose of This Form

This form authorizes Lebanon Public Schools to deduct fitness club membership fees directly from your paycheck.

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Membership Type Selection

Please select one membership type and location.

YMCA, Ozarks Regional Lebanon Family

Monthly Fees (tax included):

• Adult Membership: $37.40

• Family Membership: $55.25

• Couple / Single Adult: $50.15

• Senior Membership: $30.60

• Senior Couple: $43.35

Great Life Golf/Fitness

Monthly Fees (tax included):

• Golf & Fitness Membership: $72.74

• Fitness Only Membership: $26.35

• Other Membership Type: $________

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Payroll Deduction Terms

By signing this agreement, you acknowledge and agree to the following:

• Membership fees will be deducted automatically from your paycheck each month.

• Payroll deduction will run for 12 consecutive months.

• Membership will automatically renew unless canceled before the renewal date.

• You authorize Lebanon Public Schools to deduct the selected monthly fee from your paycheck.

• Membership rates may change based on fitness center pricing.

• The fitness center will notify you of any rate changes.

Submission Instructions

• Select your location and membership type.

• Sign and date this form.

• Submit the completed form to Payroll at Central Office.

• Additional membership paperwork must also be completed at the selected fitness center before submitting this payroll agreement.

Download 403 (b) Universal Availability Notice

Heading 2: 403(b) Universal Availability Notice

Lebanon R-III School District

Looking for help?

View your plan details online: OMNI Plan Detail Page
https://www.omni403b.com/PlanDetail

Did you know about your 403(b) benefit?

You have the opportunity to save for retirement by participating in your employer’s 403(b) retirement plan. A 403(b) plan is a retirement plan for certain employees of public schools, tax-exempt organizations, and ministries.

403bUniversalAvailabilityNotice

We recommend that all employees visit OMNI’s education page:
www.omni403b.com/Employees/Education

Why save with a 403(b)?

1. You do not pay income tax on allowable contributions until you begin withdrawals (usually after retirement).

2. Investment gains in the plan are not taxed until distribution.

3. Generally, retirement assets can be carried from one employer to another.

How to participate

Before contributing, you must open an account with an investment provider authorized in the plan. A list of approved providers is included below.

After opening your account, complete a Salary Reduction Agreement (SRA) online at:
www.omni403b.com/SRA

If you are already contributing and want to change your contribution amount or investment provider, complete and submit a new SRA.

You can begin or change contributions as soon as your next payment cycle following receipt of a completed SRA.

Contribution limits (2026)

In 2026, you may contribute:

• Up to $24,500 if you are age 49 and under (as of 12/31/2026).

• Up to $32,500 if you are age 50 to 59, or age 64 or older (by 12/31/2026).

• Up to $35,750 if you are age 60 to 63 (as of 12/31/2026).

You may also be entitled to additional catch-up provisions, such as the 15-Year Service Catch-Up. Please contact OMNI’s Customer Care Center at 877-544-6664 for details.

15-Year Service Catch-Up (if eligible)

• Additional catch-up amount: $3,000

Combined limits for elective and non-elective contributions (2026)

Combined limits for elective and non-elective contributions:

• $72,000 if age 49 and under on 12/31/2026.

• $80,000 if age 50 to 59, or age 64 or older by 12/31/2026.

• $83,250 if age 60 to 63 as of 12/31/2026.

Maximum employer contribution: $72,000

Future retirement savings value (example only)

Assumes 6% growth.

Monthly contribution: $50

• 5 years: $3,489

• 15 years: $14,541

• 20 years: $23,102

Monthly contribution: $200

• 5 years: $13,954

• 15 years: $58,164

• 20 years: $92,408

Monthly contribution: $500

• 5 years: $34,885

• 15 years: $145,409

• 20 years: $231,020

  Approved service providers

• Ameriprise Financial RiverSource

• Aspire Financial Services

• Corebridge Financial (formerly AIG VALIC)

• Equitable (formerly AXA)

• Fiduciary Trust Co of New Hampshire

• Fiduciary Trust Intl / Franklin Templeton

• Roth Aspire

• Roth Corebridge Financial (formerly AIG VALIC)

• Roth Equitable (formerly AXA)

• Roth Security Benefit

• Roth Voya Financial (ReliaStar)

• Security Benefit

• Voya Financial (ReliaStar)

• Aspire Financial Services 457

• Corebridge Financial (formerly AIG VALIC) 457

• Equitable (formerly AXA) 457

• Fiduciary Trust Co of New Hampshire 457

• Putnam Investments 457

• Security Benefit 457

• Voya Financial (ReliaStar) 457

Download: Direct Deposit Authorization Agreement (PDF)

Direct Deposit Authorization Agreement

Lebanon R-III School District — Payroll Department

Direct Deposit (ACH Credits)

Authorization

I authorize Lebanon R-III School District (the “Company”) to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries made in error to the checking and/or savings account(s) listed below at the bank named below (the “Depository”). The Depository is authorized to credit and/or debit the same to such account(s).

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Important Information

• If you are depositing to two different banks, please complete one form per bank.

• Payroll checks are deposited on the 15th of each month.

• A voided check or deposit slip must be included.

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Bank Information (Depository)

• Bank Name (Depository): _______________________________

• Bank Address: _________________________________________

• City/State: _____________________ ZIP Code: __________

• Bank Routing Number: __________________________________

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Employee Information

• Employee Name (print): ________________________________

• Date: ____________________

• Employee Signature: ____________________________________

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Checking Account Deposit Instructions

• Checking Account Number: ______________________________

Select one option (Checking):

• ☐ Deposit entire check

• ☐ Specified amount per month: $__________ (List specified amount)

• ☐ Remainder of check

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Savings Account Deposit Instructions

• Savings Account Number: _______________________________

Select one option (Savings):

• ☐ Deposit entire check

• ☐ Specified amount per month: $__________ (List specified amount)

• ☐ Remainder of check

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Notice About Changes

If you change any banking information, you must notify the Central Office Payroll Department immediately and complete a new Direct Deposit Authorization Agreement.

Download: Missed Punch Request Form (PDF)

Missed Punch Request Form

Lebanon R-III School District

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Employee Information

Employee Name: ________________________________

• Date: ____________________

• Job Title: _________________________________

• Building: _________________________________

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Missed Punch Details

Date of Missed Punch: __________________________

Type of Missed Punch

Select one option and include the time.

• ☐ Clock In: __________ a.m. / p.m.

• ☐ Lunch / Personal Out: __________ a.m. / p.m.

• ☐ Lunch / Personal In: __________ a.m. / p.m.

• ☐ Clock Out: __________ a.m. / p.m.

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Reason for Missed Punch

Select one reason below:

• ☐ Forgot

• ☐ Computer Issues

• ☐ System Down

• ☐ Other: ________________________________________

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Employee & Supervisor Signatures

Employee Signature: ____________________________

• Date: ____________________

• Supervisor Signature: __________________________

• Date: ____________________

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Office Use Only

Date Received: ____________________

• Date Entered: _____________________

• Entered By: _______________________

PSRS/PEERS Member Information Change Form (PDF)

PSRS/PEERS Member Information Change Form

Use this form to request a name change and/or address change on record with the Public School and Education Employee Retirement Systems of Missouri (PSRS/PEERS).

Important Information (Read First)

This form must be completed and returned to PSRS/PEERS. If you are changing your name:

• Please print your full name. Do not use initials or nicknames.

• Return the completed form and documentation providing proof of your name change, such as a copy of a marriage certificate, divorce decree, court order, driver's license or Social Security card. 

• Keep a copy of this form for your records.

• PSRS/PEERS will acknowledge your name or address change once processed.

If you have questions, contact PSRS/PEERS at (800) 392-6848 or visit www.psrs-peers.org.

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Required Documentation for Name Changes

If you are requesting a name change, you must:

• Print your full legal name (do not use initials or nicknames)

• Submit documentation showing proof of name change, such as:

  • Marriage certificate

  • Divorce decree

  • Court order

  • Driver’s license

  • Social Security card

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Section A: Member Information

Please complete all applicable fields.

• First Name: ______________________________

• Middle Name: ____________________________

• Last Name: ______________________________

• Member ID (or last four digits of Social Security Number): __________________

• Telephone Number: ( ______ ) __________________

• Email Address: ______________________________

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Section B: Name Change Request

Use this section only if you are requesting a name change.

• Change name from: ______________________________

• Change name to: ________________________________

• Effective Date of Change: _______________________

Signatures Required:

• Original written signature as previously written: _______________________

• Original written signature to be used in the future: _____________________

• Date: ____________________

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Section C: Address Change Request

Use this section only if you are requesting an address change.

Previous Mailing Address:

• Street Address: ______________________________

• City: ____________________

• State: ___________________

• ZIP Code: ________________

New Mailing Address:

• Street Address: ______________________________

• City: ____________________

• State: ___________________

• ZIP Code: ________________

• Effective Date of Change: _____________________

Member Signature (original written signature required): _____________________
Date: ____________________

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Where to Send This Form

Please submit the completed form and any required documentation to Dana Phillips at Central Office. The District will forward the materials to Public School and Education Employee Retirement Systems of Missouri (PSRS/PEERS) on your behalf.

PSRS/PEERS Mailing Address:
Public School and Education Employee Retirement Systems of Missouri
PO Box 268
Jefferson City, MO 65102-0268

PSRS/PEERS Contact Information:

• Phone: (573) 634-5290 or (800) 392-6848

• Fax: (573) 634-7934

• Email: psrspeers@psrspeers.org

• Website: www.psrs-peers.org