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FLEX AND DEPENDENT CARE Enrollment Form

 

Handle: Document-81234
Owner: Fuller, Tina (User-7387, tfuller:DocuShare)DS
Monday, March 19, 2012 09:34:21 AM EDT
Wednesday, October 23, 2013 09:11:31 AM EDT
Modified By: Dickenson, Rhonda (User-8396, rhonda.dickenson:gvwfl)DS
Locked By:
  • The employer maintains a Plan Document; if anything in this document conflicts with the Plan Document, then the Plan Document controls.
  • B.
  • FLEXIBLE SPENDING ACCOUNTS (FSAs) Please enter your FSA election(s) below.
  • Any choices above may be modified only as defined in the plan.
  • If a Beniversal® Prepaid MasterCard® is associated with my Flexible Spending Account:
 I authorize the issuance of a Beniversal Card by a bank chosen by Benefit Resource.
  • Signature: ________________________________________________________________________________
Date: _____ / _____ / _____ D. PAYROLL DEDUCTION I...
Allowed
Adobe Portable Document Format (.pdf) - application/pdf
fsa_enroll_201006.pdf
No
4
65110
No
Appears In: Payroll Dept.
Preferred Version: 2012 FLEX AND DEPENDENT CARE Enrollment Form