Form Hud-27012 - Federal Employees Health Benefits Program (Fehb) Premium Conversion Waiver/election Form - U.s. Department Of Housing And Urban Development

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Federal Employees Health Benefits Program (FEHB)
U.S. Department of Housing
and Urban Development
Premium Conversion Waiver/Election Form
Office of Human Resources
I.
Purpose of This Form
This form is used to elect or waive pre-tax treatment of employee premium contributions to the FEHB Program.
Pre-tax treatment is automatic. You do not need to complete this form unless you elect not to have your FEHB premium
contributions deducted on a pre-tax basis, or you previously waived this benefit and now elect to participate.
II. PARTICIPANT INFORMATION
Last Name
First Name
MI
SSN
Agency/Office Name
Agency/Office Address
Office phone
III. ELECTION TO WAIVE PARTICIPATION IN PREMIUM CONVERSION
I elect to waive participation in premium conversion and the pre-tax treatment of my FEHB premiums. I would like to have
my FEHB premium contributions deducted from my pay on an after-tax basis.
Signature
Date
This is my initial opportunity to waive participation in premium conversion
I am making this election to waive participation during FEHB Open Season
I wish to waive participation in premium conversion on account of and in accordance with a Qualifying Life Event
IV. ELECTION TO RESTORE PARTICIPATION IN PREMIUM CONVERSION
I elect to have my FEHB premiums deducted from my pay on a pre-tax basis. I understand that I may only change my
FEHB premium deductions to an after-tax basis during a subsequent Open Season or upon a Qualifying Life Event. See
instructions for acceptable events.
Signature
Date
I am making this election to participate during the FEHB Open Season
I wish to participate in premium conversion on account of and in accordance with a Qualifying Life Event
V. TO BE COMPLETED BY PAYROLL/PERSONNEL STAFF
Approved
Disapproved
Effective Date:
MM/DD/YYYY
Authorized agency official: ____________________________________
_______________________
Signature
Date
Privacy Act Statement: This information is collected under 5 C.F.R. § 892 and will be used to process your decision
to waive or restore the pre-tax treatment of your FEHB premiums. This information may also be used pursuant to
routine uses promulgated by OPM under 5 U.S.C. § 552a(b)(3). Completion of this form is voluntary. However, if
this information is not provided, we will be unable to process your waiver or restoration of premium conversion.
Page 1 of 2
form HUD-27012 (9/2000)

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