Contribution Information. Prior to your policy year under this Account-Based Offerings Administrative Services Agreement, and then for each subsequent renewal date, you must provide to Blue Cross and Blue Shield the following information: each covered employee’s annual FSA, TFS, and PFS contributions; and your contributions for each covered employee’s FSA, TFS, PFS, and HRA. If any of this information changes during your policy year, you must promptly inform Blue Cross and Blue Shield of those changes.
Contribution Information. True and full information regarding the amount of cash and a description and statement of the agreed value of any other property or services contributed by each Member and which each Member has agreed to contribute in the future. Any Member (personally or through an authorized representative) may, for any purpose reasonably related to such Member’s Interest, inspect and copy (at its own cost and expense) the books and records of the Company at all reasonable business hours.
Contribution Information. Please see the Xxxxxxxxx ESA Custodial Agreement and Disclosure Statement for general contribution and rollover guidelines. The type of contribution being made to this Xxxxxxxxx ESA must be designated in this section. Computershare Trust Company advises that you (a) check with your tax/or financial advisor before establishing a Xxxxxxxxx ESA, and (b) effect any rollover contributions from existing Xxxxxxxxx ESAs on a cash-only basis.
Contribution Information. This CESA will be funded with the following type of contribution Annual CESA contribution for Tax Year $ Tax Year $ Transfer from another CESA Rollover from another CESA Other Explain:
Contribution Information. (Select all that apply & complete amounts in part 3) **All deductions are taken on a post-tax basis** New salary reduction and/or district match amount Effective Date:* Change salary reduction amount and/or district match amount Discontinue TSA salary reduction with the following Service Provider(s): Employee’s deductions (this tax year) to all 403b plans or all 457 plans are expected to exceed $22,500/year. Employee is over age 50 and planning to deduct an additional $7,500 in the current calendar year ▪ Requests are accepted any time from September 1st – May 31st. Requests received over the summer will be held until September 1st. ▪ Completed Salary Reduction Agreement forms must be received prior to the current payroll or they will be held until the following payroll. ▪ All deductions are taken post tax
Contribution Information. (Select all that apply) Employee is utilizing catch-up provisions/special elections. Yes No If yes, please attach Maximum Annual Contribution Worksheet which can be found at xxxx://xxxxxxx.xxx/sag_forms.html Part 3. Service Provider Deduction Per Pay Service Provider By signing above, Employee acknowledges receipt of attached Part 4, Additional Terms of Agreement.
Contribution Information. (Select only those that apply) Part 2. Service Provider (Investment Company): (This section must be completed if you are participating in the Plan) Investment Company Amount Per Pay Period
Contribution Information. (Fill in all that Apply) Part 4. Agreement
Contribution Information. (Fill in all that apply) INITIATE A NEW SALARY REDUCTION: Please reduce my salary by $ or % per pay peri- od. FROM: $ or % TO $ OR % I AM AGE 50 OR OVER and eligible to contribute the maximum catch-up limit
Contribution Information. (Fill in all that apply) INITIATE A NEW SALARY REDUCTION: Please reduce my salary by $ or % per pay period. TYPE OF PLAN: (circle) 403b 457b 457Roth I understand an established account with an approved provider must be open before contributions begin. NAME of Service Provider is: FROM: $ or % TO $ OR % REPLACE MY CURRENT SERVICE PROVIDER FROM TO DISCONTINUE MY CURRENT SALARY REDUCTION with the service provider ADD SERVICE PROVIDER(S) IN ADDITION to my current provider (complete Part 3. below) I AM UNDER AGE 50 and am eligible to contribute up to the maximum annual limit I AM AGE 50 OR OVER and eligible to contribute the maximum catch-up limit EFFECTIVE DATE OF THIS AGREEMENT:
