ELECTION UNDER
SECTION 125 OF THE INTERNAL REVENUE CODE FOR PLAN YEAR 20XX
MARITAL
STATUS:
(CIRCLE) SINGLE SINGLE w/Deps MARRIED/NO Deps MARRIED w/ deps
WORK
STATUS: (CIRCLE) Full
Time (maintain 30 hours/week) Part-time
(less than 1560 hours/year)
Part-time
(work AT LEAST 1560 hours/year)
DATE
OF HIRE:
________________________________
(IMPORTANT) Effective date
of Insurance ____________________
(completed
by Employer)
MEDICAL
PREMIUM EXPENSE ([Firm Name] HEALTH INSURANCE)
If
you participate in our health insurance coverage you must elect this option
__________________
I DO ELECT ________________________
I DO NOT ELECT
Deduction
Per Pay: (before ER contribution
credit is applied) (CIRCLE ONE)
Single $XX.XX Emp/Child(ren) $XX.XX Emp/Spouse $XX.XX Family $XX.XX
DENTAL INSURANCE
PREMIUM EXPENSE
Deduction
Per Pay (CIRCLE ONE)
Single $X.XX Emp/Child(ren) $X.XX Emp/Spouse $X.XX Family $XX.XX
____
.
HEALTH
CARE REIMBURSEMENT ACCOUNT (maximum election per year $X,XXX)
__________________
I DO ELECT ________________________
I DO NOT ELECT
Salary
Redirection of $__________________________PER PAY
Reimbursements
will be available only for “qualifying medical care expenses” (see
attached). If you cease employment with
the Employer, your participation in the Plan will cease. No further contributions will be made to the
Plan on you behalf.
____ .
DEPENDENT
CARE ASSISTANCE
__________________
I DO ELECT ________________________
I DO NOT ELECT
Salary
Redirection of $__________________________PER PAY
$X,XXX
for single employee or married employee filing a combined federal income tax
return; and
$X,XXX
for a married employee filing a separate federal income tax return.
Reimbursements
will be available only for “qualifying dependent care expenses” as described in
the Internal Revenue Code Section 129, the Plan Document and the Summary Plan
Description. I agree to provide the
Administrator with a statement from the service provider that includes the
amount of the expense as proof that the expense has been incurred, along with
the name, address, and the taxpayer ID number of the service provider.
____ .
THIS
AGREEMENT IS SUBJECT TO THE TERMS OF THE EMPLOYER’S CAFETERIA PLAN, AS AMENDED
FROM TIME TO TIME IN EFFECT, SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE
WITH APPLCABLE LAWS, SHALL TAKE EFFECT AS A SEALED INSTRUMENT UNDER APPLICABLE
LAWS, AND REVOKES ANY PRIOR ELECTION AND COMPENSATION REDUCTION AGREEMENT
RELATING TO SUCH PLAN.
_____________________________________________________ Date: ____________________
Signature
____________________________________________________ Office: ____________________
Print Name
RETURN FORM TO [Name]
