SECTION 125

Health and Dependent Care Reimbursement Account

Election/Change Form-Salary Reduction Agreement


EMPLOYER: P34 McGuire Bearing | 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:

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Signature Certificate
Document name: Health and Dependent Care Agreement
lock iconUnique Document ID: a02446a274265acd3f2bceb69aeb7d9c91c07b0e
Timestamp Audit
October 18, 2023 2:22 pm PDTHealth and Dependent Care Agreement Uploaded by Jenny McGuire - jmcguire@mcguirebearing.com IP 174.174.52.169
October 18, 2023 2:24 pm PDTJenny McGuire - jmcguire@mcguirebearing.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169
October 19, 2023 11:31 am PDTJenny McGuire - jmcguire@mcguirebearing.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169
October 19, 2023 11:32 am PDTJenny McGuire - jmcguire@mcguirebearing.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169
October 19, 2023 1:50 pm PDTJenny McGuire - jmcguire@mcguirebearing.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@mcguirebearing.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169
October 19, 2023 2:47 pm PDTJenny McGuire - jmcguire@mcguirebearing.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169
October 19, 2023 2:47 pm PDTJenny McGuire - jmcguire@mcguirebearing.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169
October 19, 2023 3:00 pm PDTJenny McGuire - jmcguire@mcguirebearing.com added by Jenny McGuire - jmcguire@mcguirebearing.com as a CC'd Recipient Ip: 174.174.52.169