Dependent Name - Human Resources - Syracuse University Page 2
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2Syracuse University
Application for Schedule B Medical Contributions
Human Resources, Skytop Office Bldg., 443-4042
Adjusted Gross Income on YOUR Federal Income Tax Return:
$________
(Line 37 on Form 1040, line 21 on Form 1040A; line 4 on Form 1040EZ)
If filing separately, Adjusted Gross Income from YOUR SPOUSE/DOMESTIC
PARTNER’S Federal Income Tax Return:
$________
(Line 37 on Form 1040, line 21 on Form 1040A; line 4 on Form 1040EZ)
HOUSEHOLD
INCOME
Total Adjusted Gross Income(s) from the Federal Income Tax Return(s) of each of
your children over the age of 19 who are enrolled in your medical plan but are not
$________
included on either of the Federal Income Tax Returns above:
(Line 37 on Form 1040, line 21 on Form 1040A; line 4 on Form 1040EZ)
HR Use Only - Total Household Income
$________
The information I have provided on this form is true to the best of my knowledge and I understand
that misrepresentation of any statement on this form or the required documentation is cause for
cancellation of this benefit.
EMPLOYEE
Employee Signature _______________________________ Date _____________
CERTIFICATION
This application and all required signed Federal Income Tax Returns must be submitted to
or in person (at HR’s Office in
the Office of Human Resources via e-mail
hrservic@syr.edu
the Skytop Office building) within 31 days of your hire date.
If your application for Schedule B Medical Contributions is approved, you will be notified via e-mail
to your syr.edu account and your new rates will take effect for the 2014 calendar year (unless
otherwise noted).
APPROVED
DENIED
HR USE ONLY
_______________________________________________
___________________
Office of Human Resources
Date
HR163
Call the HR Service Center
Originated 10/20/2010
at 443-4042 for assistance
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