<p> PRE-TAX TREATMENT OF MEDICAL/DENTAL PREMIUMS</p><p>Present tax laws permit an individual’s contribution toward health care premiums to be subtracted from earnings before taxes are taken. This results in lower taxable income and lower federal, state and social security taxes. Virtually all University of Dayton faculty and staff who currently pay part of their health care premiums do so in this pre- tax manner. Lower social security taxes may cause a very slight reduction in the social security wage base.</p><p>Important: In accordance with Internal Revenue Service regulations, except for certain changes in family status, this election to have a certain dollar amount withheld from salary on a pre-tax basis for premium payment cannot be revoked until the beginning of the next health care plan contract year . Examples of changes in family status are as follows:</p><p>Marriage Divorce Death of a spouse or dependent Birth/adoption/legal guardianship of a dependent Termination or commencement of a spouse’s employment Change in your spouse’s employment status affecting benefits</p><p>If a change in family status has not occurred (e.g. your spouse’s health care premiums have changed), we are required by IRS regulations to continue your salary reductions at the same level even if you wish to drop or reduce coverage (e.g. from family to single coverage) during the year.</p><p>With your completed enrollment application, please indicate below whether or not you choose to have your premium payments made on a pre-tax basis. If you are not completing a new application because your insurance coverage will not be changing, it is not necessary for you to complete this form. Any questions may be directed to Anita Harris at (937) 229-2539 or Beth Schwartz at (937) 229-2538.</p><p>______I wish to make my premium payments to the University’s health/dental programs on a pre-tax basis.</p><p>______I do not wish to make my premium payments to the University’s health/dental programs on a pre-tax basis. Please deduct my premium payments after taxes.</p><p>Name:______(Please Print) Signature:______Date:______</p><p>Return to: Office of Human Resources, St. Mary’s, RM 118 (+1614) </p><p>Benefit Form #9</p>