Utica City School District Health & Dental Insurance Tax Deduction Form - Plan Year 7/1/2026 - 6/30/2027

Sep 19, 2026

Upload by Ben

Utica City School District Health & Dental Insurance Tax Deduction Form collects employee details and election selections for tax treatment of health and/or dental premium payments. Employees complete Section 1 with employer group information, plan year dates (7/1/2026 to 6/30/2027), and personal identifiers such as name, address, contact numbers, email, and date of birth. Section 2 requires choosing either pre-tax payroll deduction for future years or opting out. Section 3 finalizes the request with employee signature and date.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Employee Information

Tax Deduction Elections

Signature

FAQs

What does Section 2 require from the employee?

Section 2 requires selecting whether the portion of the premium paid by the employee should be deducted from paychecks on a pre-tax basis or not, for this and all subsequent years.

What are the plan year dates shown on the form?

The plan year is listed as 7/1/2026 to 6/30/2027.

What information must be provided in Section 3?

Section 3 requires the employee signature and the date.

Sep 19, 2026

Upload by Ben