Welcome John Smith
ABC Company

If the information has changed mid-year, use two lines to capture the months for which the information is valid and add the totals together. If information changed mid-month, please see the How Imputed Income is Calculated section.

Information is Valid   Benefit
  Amount:		 Age:   Employee's
  Monthly Premium
  (after tax):		   Imputed
  Income:
From: Through:
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $

For more information on Imputed Income, see Imputed Income.