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Salary Redirection Agreement  Form

Salary Redirection Agreement Form

Use a do employees need to sign a salary redirection agreement every year template to make your document workflow more streamlined.

Payroll start date / / . Health Care Account YES I elect to contribute $ (before taxes) for the PLAN YEAR, which is $ per pay period to , , . fund my account that pays qualified out-of-pocket health care expenses that are not covered by my employer’s health plan or any other health plan. NO I decline this option for this plan year and understand that I will lose all tax savings that I could receive as a participant. OPTION 2 Dependent Care Account This pays for day care expenses for a...
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