SECTION 1: EMPLOYEE INFORMATION
Please Print
NAME: SSN:
SECTION 2 - To be com
leted b
em
lo
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Check the change in status event that applies to you:
Change in legal marital status: (Marriage, divorce, annulment, legal separation, death of spouse)
Change in number of tax dependents: (Birth, adoption, placement for adoption, death)
Change of employment by you, your spouse or your dependent (Commencement or termination)
Change in work schedule that results in a change in your medical insurance eligibility
Change of dependent eligibility status: (Reached limiting age, losses or gains of student status, marriage)
Change in residence or worksite for you, your spouse or your dependent: (Moving in or out of HMO area)
Other:
Date of the Change in Status event selected above:
Requested new election amount for remaining portion of plan year:
Note: You may be required to submit appropriate documentation to verify the event.
SECTION 3: READ CAREFULL
Version 06/07
I have read and fully understand the regulations to change my election. I understand that my new Agreement Form and this
Change in Status Form must be completed within 30 days of the change in status event, and the election change I have requested
must be consistent with the change in status event. I understand any election change will be effective the later of the date of the
change in status, or on the date I request the election change. I certify that the above information is true and correct, and agree to
provide any necessary third-party documentation to verify the change in status event.
The IRS allows Cafeteria Plan participants to change their annual election for the remainder of the plan year if a
qualifying Change in Status occurs.
Complete all sections and submit to your HR Department within 30 days of the Change in Status event. The HR
Department will review your request and make a determination as to whether the request qualifies.
Please explain why your requested change is consistent with your status change. An election change is consistent
only if the election change is necessary or appropriate as a result of the status change event.
Please return your completed form to your Human Resource Department
Employee Signature
Employer Authorization Date
Date
University of Dayton
Change in Status Form
