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FLEX AND DEPENDENT CARE Change Form

 

Handle: Document-81235
Owner: Fuller, Tina (User-7387, tfuller:DocuShare)DS
Monday, March 19, 2012 09:35:07 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.
  • Dependent Care FSA $ ______________
$ ______________ C.
  • MID-YEAR CHANGE INFORMATION Please check applicable event.
  • I
authorize any election amount(s) above to be deducted from payroll as indicated.
  • Furthermore, I understand that if my Beniversal Card is used for
expenses other than eligible medical expenses or if I violate the terms of the agreement, my account may be suspended and I will reimburse the ...
Allowed
Adobe Portable Document Format (.pdf) - application/pdf
fsa_change_201006.pdf
No
4
74569
No
Appears In: Payroll Dept.
Preferred Version: 2012 FLEX AND DEPENDENT CARE Change Form