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).

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Health and Dependent Care Agreement
lock iconUnique Document ID: 7c55a58fb4ff20f2b50a862d5d31b39444a736b2
Timestamp Audit
October 19, 2023 12:05 pm PDTHealth and Dependent Care Agreement Uploaded by Jenny McGuire - jmcguire@mcguirebearing.com IP 174.174.52.169
October 19, 2023 12:11 pm PDTJenny McGuire - jmcguire@baartgroup.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169
October 19, 2023 12:12 pm PDTJenny McGuire - jmcguire@baartgroup.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169
October 19, 2023 2:05 pm PDTJenny McGuire - jmcguire@baartgroup.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169
October 19, 2023 2:48 pm PDTJenny McGuire - jmcguire@baartgroup.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169
October 19, 2023 2:51 pm PDTJenny McGuire - jmcguire@baartgroup.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169
October 19, 2023 3:01 pm PDTJenny McGuire - jmcguire@baartgroup.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169