- 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 ...
FLEX AND DEPENDENT CARE Change Form 
