Flexible

Spending Accounts

Effective January 1, your benefits program will include two valuable new features that offer you significant tax advantages: a Health Care Flexible Spending Account and a Dependent Care Flexible Spending Account.

The Flexible Spending Accounts, or FSAs, provide a tax‑advantaged way for you to pay for health and dependent care expenses not reimbursed by your benefit plans, allowing you to save money on the cost of these goods and services. There are two separate FSAs: one for health care expenses, and one for dependent care expenses. You can participate in either one or both of these accounts.

The FSAs Let You Save		The FSAs let you save on taxes on health and dependent care expenses not reimbursed by your benefit plans. The way it works is simple. The amount you elect to contribute to the FSA(s) is taken from your pay on a pre‑tax basis, before federal, state, and city income and social security taxes are withheld. Your FSA contribution is then directed to your Flexible Spending Accounts. When you incur dependent care expenses, or health care expenses not covered by your benefit plans, you are reimbursed from the appropriate FSA
How the Tax Savings Work		Each dollar you put into a Flexible Spending Account is a dollar not taxed. If, for example, you pay approximately 30% of your income in federal, state, and city income and Social Security taxes, by using an FSA you would save 30% on the health or dependent care expenses you pay for from your FSA. The following example will help you appreciate the tax savings offered by the FSAs. (For simplicity, the example assumes you pay a flat 30% in federal, state and city income and Social Security taxes.) The example assumes you spend $3,000 on health and dependent care expenses, and therefore decide to contribute $1,000 to the Health Care FSA and $2,000 to the Dependent Care FSA.
How the Tax Savings Work (continued)		Without With FSAs FSAs Annual salary $ 50,000 $ 50,000 Health & dependent care expenses (paid through the FSAs) — $ 3,000 Taxable salary $ 50,000 $ 47,000 Taxes (30%) $ 15,000 $ 14,100 Health & dependent care expenses (not paid through the FSAs) $ 3,000 $ — Take-home pay $ 32,000 $ 32,900 Savings (30% of money contributed to FSAs) $ 900 As you can see, by paying for your expenses through the FSAs you save 30%. With both methods you spend $3,000 on health and dependent care expenses, but using the FSAs leaves you with $900 more in take‑home pay. This is the money you would have spent in taxes on the $3,000 if you had not used the FSAs. The $3,000 in expenses really cost you $2,100, or 30% less.
	THE HEALTH CARE FSA	The Health Care FSA is for medical, dental, and other eligible health care expenses which are not reimbursed by a health care plan through which you have coverage.
	How Much You Can Contribute	Each plan year, January 1 to December 31 you may elect to contribute up to $5,000 to your Health Care FSA. Since there are 26 pay periods in a plan year, the maximum amount you can contribute to the Health Care FSA each pay period is $192.31. The minimum amount you can contribute to the Health Care FSA is $3.85 per pay period. Since there are 26 pay periods in the plan year, the minimum amount you can contribute to the Health Care FSA this year is $100.
	Eligible Expenses	The Health Care FSA is for expenses which are not reimbursed by a health care plan. In general, any health care expense that qualifies as a deduction on your federal income tax return is considered eligible for reimbursement from your Health Care FSA. The list below shows some common eligible Health Care FSA expenses: · your share of expenses, such as co-payments and deductibles, if applicable, under your benefit plans or any other health care plan in which you have coverage, including your spouse’s medical plan; · vision care expenses, such as eye exams, eyeglasses, or contact lenses; · hearing exams and hearing aids; · dental care expenses; and · any other expense which would qualify as a medical deduction on your tax return (also see "Ineligible Expenses" below). An expanded list of eligible expenses appears on page 10.
	Ineligible Expenses	If your medical expenses exceed 7½% of your adjusted gross income, the government allows you to take a tax deduction for these expenses on your tax return. However, if you are reimbursed for an expense through the Health Care FSA, you may not claim the same expense as a deduction on your federal income tax return. In other words, for any given expense you can use either tax‑saving method (the Health Care FSA or the deduction, if allowable), but not both. Some examples of expenses not eligible for reimbursement through the Health Care FSA include non‑medically supervised programs to stop smoking or lose weight, non‑medically necessary cosmetic surgery, non‑prescription sunglasses, non‑prescription drugs, premiums for other medical plans, and donations to voluntary health care services.

DEPENDENT CARE FSA	The Dependent Care FSA can be used to reimburse yourself for dependent care expenses which enable you, or if married, both you and your spouse, to work.
How Much You Can Contribute	Each year, you can contribute up to $5,000 of your salary to your Dependent Care FSA if you’re married and file a joint return, or if you are single. If you’re married and file separate income tax returns, the maximum you can contribute to your Dependent Care FSA is $2,500. In that situation, your spouse may contribute up to $2,500 to another Dependent Care FSA, if one is available through his/her employer. The minimum amount you can contribute to the Dependent Care FSA is $3.85 per pay period. Since there are 26 pay periods in the plan year, the minimum amount you can contribute to the Dependent Care FSA this year is $100. Your contribution amount cannot be greater than your earned income or your spouse’s earned income–whichever is less. Earned income is the salary remaining after all deductions are made for taxes (including Social Security). If your spouse is a full‑time student, or mentally or physically incapable of self‑care, the Internal Revenue Service (IRS) considers your spouse’s earned income to be $200 a month. If you have two or more dependents, your spouse is assumed to earn $400 a month.
Eligible Expenses	You can use the Dependent Care FSA to reimburse yourself for expenses which you incur to care for your eligible dependents while you work. If you are married, your spouse must also work, be a full‑time student, or be disabled. To be eligible for reimbursement through the Dependent Care FSA, dependent care expenses must be incurred to care for: · children under age 13 whom you are entitled to claim as dependents on your federal tax return; and/or · a disabled spouse or other disabled dependent who spends at least eight hours a day at your home. Eligible dependent care expenses include charges for the following services: · Care at licensed nursery schools, kindergartens, day camps (not overnight camps), and child care centers which provide day care. To qualify, the school or center must comply with state and local laws, serve at least seven individuals, and receive a fee for its services. · Services from individuals, other than a dependent of you or your spouse’s or children under age 19, who provide care in or outside your home (not routine baby-sitting, such as for going to a movie or out to dinner). · Household services (related to the care of the elderly or disabled adults or children who live with you) provided by a housekeeper, maid, cook, etc., as long as the individual is partly responsible for the well‑being and care of your qualified dependents. Please Note: If you use the Dependent Care FSA, the IRS requires that you provide the name, address and Social Security or other tax identification number of your care provider.
Ineligible Expenses	Expenses not eligible for reimbursement through the Dependent Care FSA include: · services provided by your spouse, by a child of yours younger than age 19, or by a dependent whom you claim as an exemption for federal income tax purposes; · nursing home or custodial care; · overnight camp expenses; · baby-sitting expenses when you are not working; · tuition expenses for schooling in the first grade or higher; and · expenses that you claim under the Dependent Care Tax Credit (see the following section).
Dependent Care Tax Credit	You may already be familiar with one way to save on child care expenses–the federal income tax credit for child care expenses. You may use the tax credit or the Dependent Care FSA for eligible dependent care expenses. You may not, however, use the tax credit and the Dependent Care FSA for the same expenses. Furthermore, any contributions to the Dependent Care FSA will reduce–dollar for dollar–or eliminate your tax credit. In general, you will find that the Dependent Care Spending Account offers more tax savings to you than the tax credit. However, your tax situation may be different, so you may want to consult a tax advisor to determine the best strategy for your circumstances. Please Note: If you use the federal income tax credit, the IRS requires that you provide the name, address and Social Security or other tax identification number of your care provider.

OTHER IMPORTANT INFORMATION

How To Enroll In the FSAs			To enroll in the flexible spending accounts, simply fill out the attached enrollment form indicating how much (if any) of your salary you’d like to contribute to the Health Care FSA and/or the Dependent Care FSA for the plan year, January 1 to December 31. In December you will be given an opportunity to change your elections for the next plan year. Completed enrollment forms should be returned to Carol Lewick by December 20.
REMEMBER: Enrollment forms are due December 20!				Each year, you elect to contribute a certain amount per pay period to your FSA. There are 26 pay periods in the year. For example, if you contribute $192.31 to your FSA each pay period, a total of $5,000 of your salary will be redirected to your FSA. The worksheets at the end of this brochure will help you estimate our expenses. Your maximum and minimum contribution amounts are described in the “How Much You Can Contribute” sections on pages 2 and 4.
		When estimating your expenses, keep in mind that there are certain predictable expenses that you should consider. For example, you may routinely pay for annual check‑ups for you and your family. If you typically satisfy your plan's deductible each year, you can count that amount as a predictable expense you should fund through the Health Care FSA.
How To File a Claim		When you incur a health or dependent care expense, you first pay for the service or product. Then you file a claim for reimbursement from the appropriate FSA. Claim forms are available from the Human Resources Department.
	Include the Proper Documentation	When filing a claim, be sure to include the proper documentation:
	Health Care Expenses	· for expenses not covered under any benefit plan, include an itemized bill or receipt. · for expenses covered only partially by a benefit plan, include the "EOB" (Explanation of Benefits) form. This form verifies the amount that was not reimbursed by your plan. If you and your spouse are covered under different medical plans, you must submit the EOB forms from both plans.

Dependent Care Expenses	original bills or receipts showing the name and taxpayer ID or Social Security number of the care provider (bills should state date and type of service, and for whom the service was provided).
About Reimbursements		Reimbursement checks will be made out in your name; checks may not be made out to a provider, such as a doctor, hospital, etc. For Dependent Care FSA claims, you will be reimbursed up to the amount actually in your FSA account at the time your request is received. If your claim exceeds your current FSA balance, you will initially be reimbursed for the amount of your balance. Then, as additional money is contributed to your account, you will continue to be reimbursed automatically for the amount in your account until your entire claim is paid (up to the limit, of course, of the total amount you elected to contribute to the account). For Health Care FSA claims, you can be reimbursed up to the amount you elected to contribute to the Health Care FSA. The minimum claim amount you can be reimbursed for is $25 at any one time. However, this minimum does not apply at the end of the year. Reimbursement checks will be issued every two weeks.
Reimbursement Deadline		You will have until March 31 to submit claims for expenses incurred in the prior plan year. After March 31 any money remaining in your FSA account(s) will be forfeited.
Special Limitations		The IRS imposes certain restrictions upon the Health Care FSA and the Dependent Care FSA, which are outlined in this section.
“Use It or Lose It”		The IRS requires that any money remaining in your FSA account(s) at the end of the plan year (December 31, 2000) will be forfeited unless applied to eligible expenses for that given plan year by March 31, 2001. In other words, if you do not use this money, you will lose it. Therefore, it is important to estimate your FSA expenses carefully. The worksheets at the end of this brochure will help you do this.
Elections Once A Year		Each December, you will be given an opportunity to make new contribution elections for the next plan year. The IRS requires that the amount you choose to contribute to your Health Care FSA and/or Dependent Care FSA, if any, cannot be changed during the plan year unless you have a family status change. In addition, any change in election must be consistent with your family status change. Some of the changes in family status include the following: · marriage or divorce · birth or adoption of a child · death of a dependent or a spouse · a child ceases to be an eligible dependent under the Plan · the beginning or ending of your spouse’s employment · a change from full‑time to part‑time employment, or vice versa, for you or your spouse which results in a significant change in insurance coverage; and · an unpaid leave of absence taken by you or your spouse.
Eligible Expenses		Only expenses for services that you incur during the plan year while you are an active participant are eligible for reimbursement from your FSA(s). This means that for each year you participate in an FSA, you can use the FSA to pay for services incurred only during that plan year. As explained in “Reimbursement Deadline” on page 7, you have until March 31 of the following plan year to send in claims for your FSA expenses.
Separate Accounts		The Health Care FSA and the Dependent Care FSA are separate accounts; money cannot be transferred between accounts, and you cannot use the Health Care FSA to pay for dependent care expenses, or vice versa.
Your Other Benefits Are Not Affected		Participation in the FSA(s) will not affect your other benefits which are based on your pay, such as benefits under the Life and Disability Plan. These benefits will continue to be calculated on your unreduced salary.
Social Security Might Be Affected		Since you do not pay Social Security taxes on your FSA contributions, your future Social Security benefit could be slightly reduced. Although this reduction will usually be quite small, it could occur if your taxable salary falls below the Social Security wage base ($76,000 for 2000). However, the immediate tax benefit of the FSAs should far exceed the small loss of future Social Security benefits. This brochure highlights your new benefits. Although every effort has been made to ensure the accuracy of the information described here, if there is any conflict between this announcement and the Plan documents, the Plan documents will govern. If you have any questions about the benefits discussed in this newsletter, please contact Carol Lewick

Your Health Care Flexible Spending Account Worksheet

This worksheet will help you estimate your qualified health care expenses for the plan year. Because of the “use it or lose it” rule explained on page 7, you should be conservative in your estimates. Below are some of the areas of expense you should consider when making your estimates (a complete list of allowable expenses appears on the following page):

Possible Health Care Expenses	Your Estimate
Deductibles or co-payments under your benefit plans or under your spouse’s plans	$____________
Dental expenses	$____________
Vision care expenses	$____________
Medical equipment and supplies	$____________
Professional services	$____________
Medical treatment, such as acupuncture, healing services, etc.	$____________
Other medical bills not covered by your medical plan	$____________
TOTAL	$____________ This is the amount you should redirect to your FSA.

REMEMBER, IF YOU DO NOT SPEND THE ENTIRE AMOUNT OF YOUR FSA CONTRIBUTION BY YEAR‑END, YOU WILL FORFEIT ANY REMAINING BALANCE IN YOUR FSA.

Please note: If you plan to be reimbursed for eligible health care expenses through the Health Care FSA, you may not claim the same expenses on your federal income taxes as an itemized deduction.

Expenses Deductible for Income Tax Purposes, or Eligible for

Reimbursement From Your Health Care Flexible Spending Account

General Expenses:

Medical plan deductible

Medical plan copayment

Dental and Orthodontia expenses

Vision care expenses including exams, glasses and contact lenses, and the cost of lasik eye surgery

Contact lens maintenance (drops, solutions, etc.)

Routine checkups and physicals

Routine foot care

Services for alcoholism, drug addiction and mental and nervous conditions performed outside of a hospital or skilled nursing facility

Medically necessary cosmetic surgery

Hearing Aids

Birth control pills, devices and procedures

Private duty nursing services

Services of premarital or pre‑employment physical exams, well baby care, and immunizations

Occupational therapy

Smoking Cessation programs prescribed by your physician (not including over the counter programs)

Equipment and Supplies:

Abdominal supports

Air Conditioning where necessary primarily for relief from an allergy or for relieving difficulty in breathing and providing that device does not become a permanent part of your dwelling and may be removed to other quarters

Arches

Autoette (auto device for handicapped persons), but not if used to travel to job or business

Back support

Cost of installing stair‑seat elevator for person with heart condition

Elastic hosiery

Fluoridation unit in home on advice of dentist

Heating devices

Invalid chair

Orthopedic shoes‑‑excess cost over normal shoes

Reclining chair if prescribed by doctor

Repair of special phone equipment for the deaf

Special mattress and plywood bed boards for relief of arthritis of spine

Truss

Wig advised by doctor as essential to mental health of person who has lost all hair from disease

Medical Treatments:

Acupuncture or related procedures

Healing services

Navajo healing ceremonies

Sterilization

Vasectomy

Whirlpool baths

Prescription Drugs

Miscellaneous Items:

Braille books‑‑excess cost of braille books over cost of regular editions

Clarinet lessons advised by dentist for treatment of tooth defects

Convalescent home‑‑for medical treatment only

Fees paid to health institute where the exercises, rubdowns, etc. taken there are prescribed by a physician as treatments necessary to alleviate a physical or mental defect or illness

Kidney donor’s or possible donor’s expenses

Legal fees for guardianship of a mentally ill spouse, where commitment was necessary for medical treatment

nurse’s board and wages, including Social Security taxes you pay on wages

Remedial reading for child suffering from dyslexia

Sanitarium and similar institutions

Seeing‑eye dog and its maintenance

Special school costs for physically and mentally handicapped children

Wages of guide for a blind person

Telephone/teletype costs and television adapter for closed‑caption services for a deaf person

Professional Services of:

Christian Science Practitioner

Oculist

Unlicensed practitioner if the type and quality of services are not illegal

Expenses Not Deductible for Income Tax Purposes, Nor Eligible for

Reimbursement From Your Health Care Flexible Spending Account

Antiseptic diaper service

Athletic club expense to keep physically fit

Baby-sitting fees enabling you to make doctor’s visits

Boarding school fees paid for a healthy child while parent is recuperating from illness (it makes no difference that it was done on a doctor’s advice)

Bottled water bought to avoid drinking fluoridated city water

Cosmetic surgery not medically necessary

Cost of divorce recommended by psychiatrist

Cost of hotel room suggested for sex therapy

Cost of trips for a change of environment to boost morale of ailing person, even if prescribed by a physician

Dance lessons advised by doctors as physical and mental therapy or for the alleviation of varicose veins or arthritis (however, the cost of clarinet lessons for the instrument where allowed as deduction when advised as therapy for tooth defect)

Deductions from your wages for sickness insurance under state law

Domestic help‑‑even if recommended by doctor because of spouse’s illness (but part of the cost attributed to any nursing duties performed by a domestic is deductible)

Funeral, cremation or burial, cemetery plot, monument or mausoleum

Health programs offered by resort hotels, health clubs and gyms

Illegal operations or drugs

Marriage counseling fees

Maternity clothes

Patent medicine

Premiums in connection with life insurance policies, paid for disability, double indemnity, or for waiver of premiums in event of total and permanent disability or policies for providing for reimbursement of loss of earnings or a guarantee of a specific amount in the event of hospitalization

Premiums for medical or dental insurance for spouse or dependents paid with either before or after tax dollars

Scientology fees

Special foods or beverage substitutes‑‑but excess cost of chemically uncontaminated foods over what would have ordinarily been spent on normal food was deductible for allergy patients

Toothpaste

Transportation costs of disabled persons to and from work

Travel costs to look for a place to live‑‑on doctor’s advice

Travel costs to favorable climate when you can live there permanently

Tuition and travel expenses to send problem child to a particular school for a beneficial change of environment

Veterinary fees for pet

Vitamins, tonics, etc. not prescribed by a physician

Weight reduction or stop‑smoking programs undertaken for general health, not for specific ailments

Your divorced spouse’s medical bills (you may be able to deduct them as alimony)

Your Dependent Care Flexible Spending Account Worksheet

This worksheet will help you estimate your qualified dependent care expenses for the plan year. Because of the “use it or lose it” rule explained on page 7, you should be conservative in your estimates. Below are some of the areas of expense you should consider when making your estimates:

Possible Dependent Care Expenses	Your Estimate
Amount of salary paid to in-home care provider (including Social Security and other taxes)	$____________
Day care center for dependent adult or child	$____________
Nursery school, kindergarten, day camps	$____________
Dependent adult care expenses (usually a parent being cared for in your home)	$____________
TOTAL	$____________ This is the amount you should redirect to your FSA.

REMEMBER, IF YOU DO NOT SPEND THE ENTIRE AMOUNT OF YOUR FSA CONTRIBUTION BY YEAR‑END, YOU WILL FORFEIT ANY REMAINING BALANCE IN YOUR FSA.

Please note: If you plan to claim the credit for dependent care expenses on your federal income taxes, you may not be reimbursed for those expenses through the Dependent Care Flexible Spending Account. Furthermore, any contributions to the Dependent Care FSA will reduce dollar for dollar or eliminate your tax credit.

ROSE AND KIERNAN, INC

Enrollment Form for Health Care FSA and Dependent Care FSA

Plan Year: JANUARY 1, 2000 to DECEMBER 31, 2000

Employee Information

Name __________________________________________________________ Social Security # _____ _____ ______

(please print)

Address ____________________________________________________________________________________________

City ________________________________________________________ State _________ ZIP _________________

Employee ID # _______________________ Daytime Phone Number

Flexible Spending Account Elections

Please indicate the amount of your salary you wish to contribute to the Health Care Flexible Spending Account and/or the Dependent Care Flexible Spending Account.

Health Care FSA

Number of pay periods x Contribution per pay period = Total annual contribution

26 x $ ____________ = $ ____________

($3.85 minimum, $192.31 maximum) ($100 minimum, $5,000 maximum)

Dependent Care FSA

Number of pay periods x Contribution per pay period = Total annual contribution

26 x $ ____________ = $ ____________

($100 minimum, $5,000 maximum) ($100 minimum, $5,000 maximum)

Total FSA contributions per pay period Total contribution to FSA

$____________ $____________

Authorization

Please read the statement below, then sign and date this form. The forms must be returned to Carol Lewick by December 20.

I authorize the redirection of my salary (on a per paycheck basis) for contributions to my Health Care Flexible Spending Account and Dependent Care Flexible Spending Account. I understand that such redirections will be made on a pre‑tax basis.

I understand that amounts redirected from my pay and not used for health and/or dependent care expenses incurred during the Plan year will be forfeited in accordance with Internal Revenue Service regulations. I also understand that this authorization is irrevocable until the next Plan year unless I have a change in family status (i.e., marriage, divorce, birth or adoption of a child, termination of spouse's employment or health insurance, etc.).

SIGNATURE ______________________________________________________DATE ___________________________

ROSE AND KIERNAN, INC

Health Care FSA Claim Reimbursement Form

Employee Information

Name __________________________________________________________ Social Security # _____ _____ _______

(please print)

Address _________________________________________________________________________________________________

City ________________________________________________________ State _________ ZIP _________________

Employee ID # _______________________ Daytime Phone Number

List of Expenses

Please attach bills, statements, or other proof of expenses. Canceled checks are not sufficient evidence. “Explanation of Benefits” (EOBs) from medical plan(s) are also required as proof of amounts not fully reimbursed by medical plan(s).

Date of Service	Name of Provider	Service Provided	Amount
Total Expenses $

Spouse and Dependent Information* (if expenses are for your spouse or for a dependent)

____________________________________________________________________________________________________

Name Date of Birth Relationship

____________________________________________________________________________________________________

Name Date of Birth Relationship

* Your dependent is your child, stepchild, parent, other close relative, or a person who lives in your home and for whom you provide over half of his/her support.

Signature

I certify that the expenses listed above qualify for reimbursement and have been incurred and paid by me or by eligible members of my family. These expenses have not been reimbursed by my health care plan or any other health care plan, such as my spouse's. Additionally, these expenses are not being claimed as tax deductions under Section 213 of the IRS code. Bills, statements, or other proof of these expenses are attached.

SIGNATURE __________________________________________________________ DATE ______________________

Please Return To: ADP Benefit Services PO Box 1853 Alpharetta, GA 30023-1853

FOR INTERNAL USE ONLY Amount Paid ____________________________ Account/Employee # _____________________

Date Paid _____________________ Approved by __________________

ROSE AND KIERNAN, INC

Dependent Care FSA Claim Reimbursement Form

Employee Information

Name __________________________________________________________ Social Security # _____ _____ _______

(please print)

Address _________________________________________________________________________________________________

City ________________________________________________________ State _________ ZIP _________________

Employee ID # _______________________ Daytime Phone Number

List of Expenses

Please attach bills, statements, or other proof of expenses. Canceled checks are not sufficient evidence.

Date of Service	Name of Provider	Taxpayer ID # or SS# of Provider	Service Provided	Amount
Total Expenses $

Dependent Information*

______________________________________________________________________________________________________________

Name Date of Birth Relationship

______________________________________________________________________________________________________________

Name Date of Birth Relationship

* Your dependent is your child, stepchild, parent, other close relative, or a person who lives in your home and for whom you provide over half of his/her support.

Signature

I certify that the expenses listed above qualify for reimbursement and have been incurred and paid by me or by eligible members of my family.

I understand that I have the responsibility for any tax reporting or other legal requirements with respect to reimbursable expenses. I also understand that to the extent dependent care expenses are reimbursed under the Dependent Care Flexible Spending Account, they may not be claimed as expenses for purposes of the dependent care federal income tax credit.

SIGNATURE __________________________________________________________ DATE ___________________________

Please Return To: ADP Benefit Services PO Box 1853 Alpharetta, GA 30023-1853

FOR INTERNAL USE ONLY Amount Paid ____________________________ Account/Employee # _____________________

Date Paid _____________________ Approved by __________________

ROSE AND KIERNAN, INC

Account Change of Election Form

Employee Information

Name __________________________________________________________ Social Security # _____ _____ _______

(please print)

Address _________________________________________________________________________________________________

City ________________________________________________________ State _________ ZIP _________________

Employee ID # _______________________ Daytime Phone Number

I request a change in my FSA election for the following reason:

q Marriage/divorce

q Birth/adoption of a child

q Death of dependent/spouse

q Loss of dependent child's eligibility status

q Beginning or ending of spouse's employment

q Change in full‑time/part‑time status for spouse which results in change in insurance coverage

q Unpaid leave of absence taken by you or your spouse

My current Health Care My current Dependent Care

FSA Annual Election is $_______________ FSA Annual Election is $_______________

My revised Health Care My revised Dependent Care

FSA Annual Election is $_______________ FSA Annual Election is $_______________

Authorization

SIGNATURE __________________________________________________________ DATE ___________________________

Please return this form to hr@rkinsurance.com.