SECTION 125

Health and Dependent Care Reimbursement Account

Election/Change Form-Salary Reduction Agreement

EMPLOYER: P34 Baart Group | PLAN YEAR: 11/1/2023 – 10/31/2024

Personal Information

Employee SSN:

Name:

Date of Birth:

Email:

Phone Number:

Address:

Branch / Division:

Initial Elections

Health Care Deduction: /per pay period // annually

Dependent Care Deduction: /per pay period // annually

Authorization

I have read the enrollment material and understood its terms as they may apply to me. The amount deducted from my pay is not subject to Federal, State, or Social Security taxes. As a result, my Social Security retirement benefit may be affected. I cannot change or revoke my election during the plan year unless there is a change in my family status (e.g., birth or adoption of a child, marriage, divorce, death of a family member).

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Your legal name

Your email address

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Timestamp

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October 19, 2023 12:05 pm PST

Health and Dependent Care Agreement Uploaded by Jenny McGuire - jobs@mcguirebearing.com IP 174.174.52.169

October 19, 2023 12:11 pm PST