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ARCHDIOCESE OF MIAMI by hG9ux5

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									                                    ARCHDIOCESE OF MIAMI
                                SALARY REDUCTION AGREEMENT

                                           Dependant Health
                                           Employee Health


                                               Declination

[ ] Under the Section 125 Plan, I choose not to participate in the Archdiocese of Miami Section 125 Plan
for Dependent Health. I understand that if I am currently participating in the Dependent Health by payroll
deduction, this declination has no effect on that participation.

[ ] Under the Section 125 Plan, I choose not to participate in the Archdiocese of Miami Slary reduction
Plan for Employee Health. I understand that if I am currently participating in the Employee Health by
payroll deduction, this declination has no effect on that participation.


                                                   OR

                                             Authorization

[ ] I hereby authorize the Archdiocese of Miami to reduce my taxable salary to pay for:

                                        [ ] Dependent Medical

                                         [ ] Employee Medical

as non-taxable benefits under the Section 125 Plan.       I have applied for dependent medical and/or
employee medical on a separate application form.

I understand that the amount of the salary reduction will be the current cost as announced by the
Archdiocese of Miami, and that having made this election my income subject to Federal Income Tax and
Social Security withholding will be reduced which may affect the amounts that I or my dependents
receive from Social Security. I understand that this salary reduction agreement can not be revoked during
the current calendar year unless there is a substantial change in my family or employment status.




        ____________________________________                 ______________________________
                   Name (please print)                                  Signature



        ____________________________________                 ______________________________
                     Social Security Number                               Date

								
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