Salary Reduction Agreement for Benefits Change

Employee Information

Employee Name: Employee ID: Department: Effective Date:

Benefits Change

Select Benefit(s) Changed: Reason for Change:

Salary Reduction Details

Benefit Type	Current Deduction	New Deduction

Agreement

I authorize my employer to reduce my salary as described above for my participation in the selected benefit plan(s). I understand that this agreement is legally binding and can only be changed as permitted by the plan or by law.

Employee Signature:

Date:

Authorized Employer Signature:

Date: