DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
ELECTION FORM
Plan year:
January 1, 20xx - December 31, 20xx
Plan Year
Maximum Contribution: $5000.00
In accordance with IRS regulations governing CNM’s Section 125 Plan, each employee is given the opportunity to make appropriate changes to his/her Dependent Care Spending Account deductions and Pre-Tax Premium Plan to suit her/his individual needs.
A
new form must be completed to
participate in the new plan year,
even if you have participated previously.
Please
check one of the following options:
______
I currently participate
and wish to continue in the Dependent
Care Spending Account. Please
deduct a total of $_____________________*per pay period (pp) dependent care expenses for the total period
January 1, 20xx through December 31, 20xx
*Or
Annual election amount requested $________________.
_______I
do not currently participate and wish to start participating in the Dependent
Care
Spending Account as of January 1,
20xx. Please deduct a
total of $____________*per pay
period for dependent care expenses for the total plan year January 1,
20xx through December 31, 20xx.
*Or
Annual election amount
requested $__________.
(Payroll deduction amount to be determined)
_______
I do not wish to participate in the Dependent Care Spending Account for Plan
Year 20xx.
NOTICE:
Only those qualified Dependent Care expenses that qualify and are eligible under the IRS as described in Publication 503 are eligible for reimbursement. Please be advised that the CNM Pre-Tax Plan Summary may not contain all the details of the governing IRS regulations. Therefore, I agree to hold CNM harmless if any damages or losses occur to me, including penalty and interest assessed by the Internal Revenue Service, if the summary has failed to adequately advise me.
All participants are strongly advised to plan their deductions carefully as the “use it or lose it” Internal Revenue Service (IRS) rule applies for the full plan year.
I
authorize CNM to withhold my pre-tax contribution selected on this form.
I also understand that I cannot
change this option for the remainder of the plan year, unless
my family status changes. I
understand that I have 90 days after the close of the plan year, to file
claims for expenses that were incurred between January 1, 20xx through
December 31, 20xx.
_____________________________
_____________________________
Employee
Signature
Please Print Name
_____________________________
_____________________________
HR 12/98