Flexible Spending Accounts

2013 Annual Election for Medical Flex Spending: <MEDICAL FLEX>

2013 Annual Election for Dependent Care Flex Spending: <DEPENDENT FLEX>

2014 Elections:

Medical:                    $_________________      x     ____________ =   $ Auto calculate

                                    

(Amount per pay period)                  (# of pay periods)          (Plan Year Election)

  Regular medical flex (For medical, vision, and dental reimbursements. Cannot be also enrolled in an HSA.)

OR

  Limited-purpose flex (For vision and dental reimbursements only. Can be enrolled in both a limited-purpose flex and an HSA)

Dependent Care:    $_________________      x     ____________ =   $ Auto calculate

           (Amount per pay period)                  (# of pay periods)          (Plan Year Election)

I elect to not participate in BOTH Medical and Dependent Care Flexible Spending Accounts in 2014.

If the check-box directly above is not marked, prompt for the following to display:

   I authorize my employer to redirect my salary according to this agreement, and I will review my paycheck to verify that my employer has made appropriate withholding consistent with my election.

This salary redirection agreement for my reimbursement account(s) will continue until:

I terminate employment with the employer listed above; or

I have a qualifying status change (see Summary Plan Description) and I modify this agreement consistent with the change; or

The end of the current plan year; or

My employer terminates, suspends, or modifies this plan or the benefits under the plan