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PAYROLL ALLOTMENT FORM Dental and the Non-Qualified LTD Benefit run March 1 2014 Feb 28 2015. The Health Insurance Runs Dec 1 2014 Nov. 30 2015 as well as all the other coverages listed below. MUST BE COMPLETED REGARDLESS IF ENROLLING IN ANY PLAN OR NOT SPECIALIZED YOUTH SERVICES OF VIRIGNIA INC. Employee Name SSN -- Address City State Zip Code Home Phone Number Date of Birth Date of Hire Salary Qualified Benefit election for Salary Reduction I elect to allocate the following amounts on a...

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