If you experience a change in family
status, you will have 30 days following the change to make any
revisions to your participation in the Section 125 Plan. You will not be
able to change your
participation after that 30-day period until the next open enrollment.
Please fill in the date the change in
family status occurred, and mark the box next to the change in
family status you have experienced. Attach documentation of the change
(such as a birth certificate,
marriage license, etc.), and sign and date the form. Please return the
completed form within 30
days of the change to your Human Resources Department.
Date of change in family status:____________________________
Effective for the Payroll Date beginning:______________________
Change:
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Your marriage
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Your divorce or legal separation
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Death of a spouse or dependent
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Birth or adoption of a dependent
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Termination or commencement of your spouse's
employment
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Change from full-time to part-time employment for you
or your spouse
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Commencement of an unpaid leave of absence for you or
your spouse
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Change in dependent care provider
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Significant change in your group health
coverage or your spouse's group health
coverage attributable to your spouse's employment
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Change my Medical Expense witholdings
from: $_______ per payroll to:$________
Change my Day Care witholdings from: $_______ per
payroll to:$________
*Payrolls Remaining in Plan Year : _______________
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