YTCD - Flex Benefit

IRC Section 125 Flexible Benefits Plan-- Employee Enrollment Affidavit
To all Eligible Employees for the IRC Section 125 Flexible Benefits Plan - 2023 Plan Year

This is your Summary Plan Description. The wait period for elegibility is 1st of the month.

Plan Year is 1-1-24 to 12-31-24.

The Administrator is: Rabbi Chaim Abrams, for the 21st Plan Year

This summary plan description will provide a general overview of the IRC Section 125 Flexible Benefits Plan, which is a benefit program that allows you to choose among specific benefits that are not subject to Social Security Tax, Federal Income Tax, or State Income Tax.

This summary plan description should be carefully reviewed so that you can understand the porovisions of the plan.

There is a plan document on file with the employer that provides detailed informatiuon on the operation of the plan.

If there is a conflict between the summary plan description and the plan document, the summary plan description will be disregarded and the acutal plan provisions will be controlling. The Plan Administrator shall interpret the terms and conditions of the Plan Document. If you want a further explanation of the Plan, you should contact the Plan Administartor.

No language contained within the plan creates a vested right to the benefits offered herein.
IMPORTANT FACTS ABOUT THE PLAN

1. Name of Plan: Yeshiva Toras Chiam Talmudical __ IRC Section 125 Flexible Benefits Plan

2. Effective Date Plan __4-18-2004__

3. Employer Sponsoring the Plan:__Yeshiva Torae Chiam Talmudical__ 1555 Stuart Street, Denver, Co. 80204

4. Employers Federal Identification Number:__84-0576800

5. Employers Plan Identification Number:__502__

6. Plan Administrator: The Plan Administration of the Plan is the Employer; the name, address, and telephone number of which are listed above.

7. Legal Agent-- The Employer has designated _Rabbi Chaim Abrams_ for service of legal process at the said address listed above.

8. Type of Plan-- The plan is a Flexible Benefits Plan governed by Internal Revenue Code Section 125.

9. Funding-- The plan shall be funded primarily by Employee Compensation Redirection Agreements.
Company Name: Yeshiva Toras Chaim Talmudical

1-1-24 to 12-31-2024
Employee Name*

First Name and Middle InitialLast Name
Employee Email*
example@example.com
Social Security Number (Not Necessary if available):
All employees must complete this enrollment affidavit to either participate or waive out of the IRC Section 125 Flexible benefits Plan for the Plan year stated above. Please complete this top section, check the appropriate box, sign and date the form.
Would you like to participate in the Flexible Benefits Plan?*

I hereby elect to participate in the Plan effective 1/1/24 and authorize my employer to reduce my gross compensation in the amounts stated below.I hereby elect NOT to participate for this Plan Year.
Employee Signature

Clear
Eligible Premium Reductions(Thru payroll) 24 Pay Periods
Health, Dental, Vision, Disability, Cancer/ Int. Care, Term Life, etc.*
Medical Expense Reimbursement($3,200.00) Max - Note New*
Dependent Care Expenses ($5,000.00 annually) Note New*
I understand that once I am a participant, I cannot change my deduction amounts during the Plan Year unless a qualifying status change occurs. I further understand that the amounts allocated to each reimbursement account must be used with the Plan Year, or the unused portion will be forfeited to my Employer. Unused amounts cannot be used to fund another account or carried forward to the next plan year. I accept the rules for participating in the IRC Section 125 Flexible Benefits Plan, and certify this affidavit is true, correct and complete. Date: 12/31/23
Employee Signature

Clear
Should be Empty:

IRC Section 125 Flexible Benefits Plan-- Employee Enrollment Affidavit

Eligible Premium Reductions(Thru payroll) 24 Pay Periods