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Af 2530 Form: What You Should Know

Female). All letters following M and F must be capitalized, even if the word ``male or female'' is left blank in the header. July 1, 2023 — SF 2809, Health Benefits Election Form Part B — Enrolled and Family Member's Information. November 1, 2023 — SF 2809, Health Benefits Election Form Part C — Family Member's Information. May 1, 2023 — SF 2809, Health Benefits Election Form Part D — Health Benefits Program (for Family Member Status Change) September 1, 2023 — SF 2809, Health Benefits Election Form Part E — Eligibility and Eligibility Status Changes for Health Benefits. Complete all blocks (D = Deductions, X = Credits, and Z = Adjustments) and enter the appropriate value. If more than one change in eligibility status is noted, complete the last block. In no case may the cost of an item, service plan, or coverage be increased to the amount paid before the date of application. Inquire if the current employee has health insurance coverage. Note the total coverage required under the plan by using the following formula: x — z = If the employee's coverage is paid by a state, the following table shows which state taxes may be due. State % of Employer's Employee's Payable (x) Annual State Tax (% of Payable (x)) Alabama 15% Alaska 1.5% California 1% Connecticut 1% Florida 1% Hawaii 1% Idaho 1.5% Illinois 1.5% Indiana 1% Kansas 1% Kentucky 1% Massachusetts 1% Maryland 1% Maine 1% Michigan 1% Minnesota 1% Missouri 1% Montana 1.5% Nebraska 1% New Jersey 1% North Dakota 1% Nevada 1.5% New York 1% N/A 1.5% Ohio 1% Oklahoma 1% Oregon 1% Rhode Island 1% Vermont, Commonwealth of Puerto Rico 15% Washington 1% Wisconsin 1% Note: -- In some places, such as Illinois, employees may elect to pay the applicable state income tax rather than have Medicare withholding withheld.

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