Authorization For Cancellation Of Voluntary Deductions printable pdf download

Anne Arundel County Public Schools | Division of Human Resources | Benefits Office

Authorization for Cancellation of Voluntary Deductions

Place a check mark to the left of the item to be cancelled. Write

√

Deduction

Amount

See Note

in the current amount of the deduction to be cancelled. When

AEL Dues

—

completed, please return form to: Anne Arundel County Public

AFSCME-AFL/CIO Dues

Note 5

Schools • HR/Benefits, 2644 Riva Road, Annapolis, MD 21401.

AFSCME Insurance

—

The effective date is subject to the date of the receipt of this

Cigna Voluntary Insurance

Note 1

form in the HR/Benefits Office and the cut-off date of work to

be entered for payroll processing.

Credit Union Savings

Note 2

All Other Savings Accounts

—

Notes

Educators Insurance

Note 2

United Way pledge, Unum Long-Term Care Insurance, Cigna

Employee Plan Services (EPS) Insurance

Note 3b

Voluntary Life Insurance, and 403(b) and 457(b) may be

Horace Mann Insurance — Income

—

cancelled anytime. HR/Benefits must be notified by comple-

tion of this form if a 403(b) or 457(b) deduction is cancelled,

Horace Mann Insurance — Life

—

otherwise payroll deductions will continue.

NEA Insurance

Note 6

Employee should contact the following directly, who will notify

United Way Charity

Note 1

HR/Benefits to terminate deductions.

U.S. Savings Bonds

—

Educators Financial Group, LLC

SAAAAC Dues

Note 4

901 Dulaney Valley Road, Suite 700

TAAAC Dues

Note 3a

Towson, MD 21204

Unum Long-Term Care Insurance

Note 1

443-279-0277 or 800-265-8787 | 410-823-4144 (fax)

√

403(b) or 457(b) Deduction

Amount

See Note

A.A. County Employees’ Federal Credit Union

CitiStreet (Travelers)

2661 Riva Road

Horace Mann Annuities

8436 Veterans Highway

(across from BOE)

Millersville, MD 21108

INA

Building 700

410-222-7283

Annapolis, MD 21401

Lincoln National

410-222-7283

Merrill Lynch

Note 1

a. TAAAC sponsored insurance is conditional upon

Met Life Resources

membership in TAAAC. Cancellation of TAAAC dues

Northwestern Mutual

requires cancellation of TAAAC sponsored insurance.

Prudential

Such cancellation can only be made in writing to

TAAAC between August 15

and September 1

. If

SYMETRA

you decide to pay your own dues directly to TAAAC,

VALIC

have TAAAC notify HR/Benefits so that the TAAAC

Employee Name (Print)

insurance may be continued.

b. To cancel your TAAAC, AEL, or SAAAAC-sponsored EPS

Signature

Date

insurance, contact EPS at the number below.

Cancellation requests will not be taken from this form.

Social Security Number

Cancellation

Effective

Employee Plan Services (EPS-AFLAC, Hartford)

Date

10111 Colesville Road, Suite 123

Location/School

Silver Spring, MD 20901

301-585-4990 or 877-884-3784

Comments

SAAAAC dues may be cancelled only during certain time

periods. Refer to Article 3, Section 3.10 of the negotiated

agreement, or contact your union representative.

AFSCME dues may be cancelled only during certain time

periods. Refer to Article 2, Section 2 of the negotiated

agreement, or contact your union representative.

To stop TAAAC-sponsored NEA deductions, contact

BCL Systems (3

party administrator) at 1-888-805-3919.

To be completed by Human Resources/Benefits

Healthcare Deductions

Entered By

Audited By

Healthcare coverage (medical, dental, or vision) may only

Effective Date

be changed or cancelled when there is an approved lifestyle

change and the change is made within 31 days of the

event. For more information, contact HR/Benefits at

AACPS • Division of Human Resources • Benefits Office • DPS/SG • 2050/7 (Rev. 4/09)

410-222-5219/5221. To obtain a required Lifestyle Change

Form, go to aacps.org>Human Resources>Forms.

Authorization For Cancellation Of Voluntary Deductions

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