IRS Code
Section 125 Election Form
for the
Medical and Dental Pretax Benefits Plan
I, ___________________________________________________,
(employee)
___ do authorize and direct
___ do not authorize
Stevens County Rural Library District to reduce my salary in the amount necessary to pay for my medical and dental insurance premium payroll deductions. Such reductions considered as elective contributions under the Plan, shall commence with my paycheck dated __________________________. I further authorize additional reductions in the event that the cost of coverage under any insurance is increased during the Plan Year.
The selection will remain in effect until a subsequent election form is filed.
I understand that a selection on this form does not necessarily include me for coverage under any insurance. In most instances an application for insurance must also be completed.
This election form will remain in effect and cannot be revoked or changed during the Plan Year, unless the revocation and new election are on account of and consistent with a change in family status (e.g., marriage, divorce, death of spouse or child, birth or adoption of child, and termination of employment of spouse).
Date: _________________ Signature of Employee: ___________________________________________
Social Security Number: ______________________
Date: _________________ Accepted by Employer: ___________________________________________
Note: All Capitalized terms are defined in the PLAN documents.
IRS
Code Section 125 Election Form: