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Flexible Benefit Plan Election Salary Reduction Form Administered by: NyhartUniversity of Southern Indianapolis Year: 2020Employee Information (please print or type) Name (Last, First, MI) Employee

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5. If there are any checkboxes or multiple-choice questions, select the appropriate option.
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7. If you need to sign the form, do so in the designated space using your full legal signature.
8. Review the completed form once again to ensure all information is filled out correctly.
9. Submit the form as instructed, either by mailing it or submitting it online.
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