Common Contracts
1 similar Salary Redirection Agreement contracts
Plan Year Employer Name Salary Redirection Agreement 1. Participant Infor mationSalary Redirection Agreement • October 18th, 2019
Email -(Required for account notifications) Eligibilit y Date Effective Date 2. Benefit Election Initial Enrollment Renewal Waive Participation Medical FSA: $ per pay period X no. of deductions = $ annual election (Must not exceed your company maximum) Dependent Care FSA: $ per pay period X no. of deductions = $ annual election ($5,000 maximum annual election for single parent and married couple filing joint tax returns and $2,500 for married couple filing separate tax returns) Transportation Benefit: $ per pay period X no. of deductions = $ annual election Parking Benefit: $ per pay period X no. of deductions = $ annual election *By signing this form I authorize my employer to deduct from my paycheck as shown above for my FSA elections.
