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ELECTION FORM <br />Name• <br />Department.- <br />Contributions: <br />epartment: <br />Contributions: (Both options must be selected at the time of enrollment) <br />"Irrevocable" Election for Pre -Tag Contributions from Bi -Weekly Pay: <br />I hereby direct my employer to deduct % or $ <br />from my pay per pay period as pre-tax elective to my VANTAGECARE <br />Retirement Health Care Savings Account. <br />"Irrevocable" Election of Pre -Tax Contribution of Accrued Leave: <br />Upon separation of employment, I herby direct my employer to make a <br />contribution of my severance pay that I have accumulated. <br />% of Unused Personal Leave. <br />Number of Hours (Maximum of 600 hours) <br />I hereby acknowledge that during my employment my election is "irrevocable." <br />I may not increase or decrease the amount of my contributions or discontinue <br />my participation in the VANTAGECARE Retirement Health Care Savings <br />Plan. <br />ICMA-RC has obtained the advice of counsel that irrevocable elections are <br />allowable under the conditions outlined in the VANTAGECARE Retirement <br />Health Savings Plan adoption materials. At this time, the Internal Revenue <br />Service has not ruled on irrevocable elections in an integral part trust. <br />Signed: <br />49 <br />Date: <br />