Previous Page  22 / 24 Next Page
Information
Show Menu
Previous Page 22 / 24 Next Page
Page Background

Please complete and submit this worksheet to your employer. This is an internal document used by your employer for data collection

purposes. Worksheets submitted to Discovery Benefits will not be processed.

5HTXLUHG )LHOGV

6WHS 3DUWLFLSDQW ,QIRUPDWLRQ

-XQHDX &RQVWUXFWLRQ &RPSDQ\

(PSOR\HU 1DPH 'R QRW DEEUHYLDWH

(PSOR\HH ,GHQWLILHU 1XPEHU

3DUWLFLSDQW 1DPH )LUVW 0, /DVW

6RFLDO 6HFXULW\ 1XPEHU

3DUWLFLSDQW 0DLOLQJ $GGUHVV

(PDLO $GGUHVV ,I SURYLGHG DOO QRWLILFDWLRQV ZLOO EH VHQW YLD HPDLO

&LW\

6WDWH

=LS

'D\ 7HOHSKRQH

%LUWK 'DWH PP GG \\\\

+LUH 'DWH PP GG \\\\

+LUH 'DWH PP GG \\\\

*HQGHU

3OHDVH FLUFOH RQH 0DOH )HPDOH

6WHS (PSOR\HH 3UHPLXPV

,I \RX KDYH D SD\UROO GHGXFWLRQ IRU LQVXUDQFH SUHPLXPV HOLJLEOH SUHPLXPV ZLOO EH GHGXFWHG EHIRUH WD[HV DUH FDOFXODWHG <RX ZLOO DXWRPDWLFDOO\ EH HQUROOHG LQ WKLV SRUWLRQ RI \RXU

6HFWLRQ 3ODQ +RZHYHU LI \RX ZLVK \RX PD\ RSW RXW RI WKH (PSOR\HH 3UHPLXP &RQYHUVLRQ SDUW RI WKH 3ODQ E\ FRQWDFWLQJ \RXU +5 'HSDUWPHQW DQG ILOOLQJ RXW WKH ZDLYHU

IRUP 3OHDVH 1RWH ,QVXUDQFH SUHPLXPV DUH QRW HOLJLEOH IRU UHLPEXUVHPHQW ZLWK \RXU 0HGLFDO RU /LPLWHG 0HGLFDO 6SHQGLQJ $FFRXQW

6WHS (QUROOPHQW DQG (OHFWLRQ ,QIRUPDWLRQ

3ODQ 7\SH

LI HQUROOHG LQ DQ +6$ \RX DUH QRW HOLJLEOH WR HQUROO LQ WKH

0HGLFDO )6$ +RZHYHU \RX DUH HOLJLEOH IRU ERWK WKH /LPLWHG 0HGLFDO )6$ DQG

'HSHQGHQW &DUH )6$ LI RIIHUHG WKURXJK \RXU HPSOR\HU

0HGLFDO )6$

/LPLW VHW E\

HPSOR\HU

'HSHQGHQW &DUH

$FFRXQW

/LPLW VHW E\ HPSOR\HU

XS WR ,56 PD[LPXP

/LPLWHG )6$

/LPLW VHW E\ HPSOR\HU LI

WKLV SODQ W\SH LV RIIHUHG

$QQXDO (OHFWLRQ

(if employer funded, note ‘ER’ next to amount)

1XPEHU RI 3D\ 3HULRGV

LI HQUROOLQJ PLG \HDU SOHDVH HQWHU WKH QXPEHU

RI UHPDLQLQJ SD\ SHULRGV ZLWKLQ WKH SODQ \HDU

÷

÷

÷

3HU 3D\ 3HULRG $PRXQW

WR EH GHGXFWHG HDFK SD\ SHULRG

=

'DWH RI )LUVW 3D\UROO

PP GG \\\\

3DUWLFLSDQW (IIHFWLYH 'DWH

PP GG \\\\

3D\ )UHTXHQF\

SOHDVH FLUFOH RQH

0RQWKO\ 6HPL 0RQWKO\ %L :HHNO\

%L :HHNO\

:HHNO\ 2WKHU

6WHS $XWKRUL]DWLRQ

, DXWKRUL]H P\ HPSOR\HU WR UHGXFH P\ SD\ RQ D SHU SD\ SHULRG EDVLV DV LQGLFDWHG DERYH , XQGHUVWDQG P\ UHGXFWLRQ LV IRU RQH IOH[ SODQ \HDU DQG WKDW , FDQQRW FKDQJH RU UHYRNH

P\ HOHFWLRQ XQOHVV , H[SHULHQFH D TXDOLI\LQJ HYHQW LQ DFFRUGDQFH ZLWK ,QWHUQDO 5HYHQXH &RGH 6HFWLRQ DQG VXEPLW P\ UHTXHVW ZLWKLQ D UHDVRQDEOH DPRXQW RI WLPH DV

GHHPHG E\ WKH ,56 DQG P\ HPSOR\HU , DP DZDUH RI WKH SODQ V IRUIHLWXUH SURYLVLRQ DQG WKDW P\ 6RFLDO 6HFXULW\ DQG IHGHUDO XQHPSOR\PHQW EHQHILWV PD\ EH UHGXFHG EHFDXVH RI

P\ UHGXFHG VDODU\ IRU WD[ SXUSRVHV )XUWKHU , DXWKRUL]H WKH UHOHDVH RI DQ\ LQIRUPDWLRQ QHFHVVDU\ WR VXEVWDQWLDWH FODLPV VXEPLWWHG DJDLQVW P\ )OH[LEOH 6SHQGLQJ $FFRXQW

6WHS 5HIXVDO

(**NOTE: only complete this step if you are NOT electing to enroll in a Flexible Spending Account)

, XQGHUVWDQG WKDW LI , FKRRVH QRW WR SDUWLFLSDWH LQ D )OH[LEOH 6SHQGLQJ $FFRXQW )6$ , FDQQRW HQWHU WKH SURJUDP XQWLO WKH QH[W SODQ \HDU XQOHVV , H[SHULHQFH D VWDWXV FKDQJH LQ

DFFRUGDQFH ZLWK ,QWHUQDO 5HYHQXH &RGH 6HFWLRQ DQG VXEPLW WKH FKDQJH ZLWKLQ GD\V RI WKH VWDWXV FKDQJH

0DULWDO 6WDWXV

3OHDVH FLUFOH RQH 0DUULHG 6LQJOH

3DUWLFLSDQW 6LJQDWXUH

'DWH

3DUWLFLSDQW 6LJQDWXUH

'DWH

)OH[LEOH 6SHQGLQJ $FFRXQW )6$ 'DWD &ROOHFWLRQ

:RUNVKHHW