American Health Centers
Affliated Companies
Section 125 Election Form
YES, I Elect to use pre-tax dollars to fund benefit contributions under my Employer's Section 125 Plan. As an eligible employee in this plan, I acknowledge that I understand the benefits available to me.
I hereby authorize my employer to redirect my income in accordance with the terms of the Plan. You may redirect my income by an amount equal to my share of the cost of the benefits listed below and credit it to my plan account.
This election will go into effect on the effective date, or if the plan effective date has already occurred, on the first Plan anniversary date coincident with or next following this election.
I elect the following benefits and authorize payment of my share of the cost of these benefits. Please check below.
Accepted and agreed to the day of December, 2005
Please type your Name:
Please type your Location:
Please Sign by typing your birthday and last 4 digits of your social security number.
Employee's Electronic Signature: (MMDDYY####)
Example: A Birthday of Febuary 14, 1961 and 2345 being the last 4 digits of a Social Security number,would be entered as: 0214612345
NO, I do not wish to allow a salary reduction under my employer's Section 125 Plan. I wish to have my requested contributions to the cost of my employee benefits from my income after federal and state taxes have been withheld for the plan year.
