HEALTH CARE FLEXIBLE SPENDING ACCOUNT
Plan year: January 1, 20XX - December 31, 20XX
Plan Year Maximum Contribution:    $3000.00

In accordance with IRS regulations governing CNM’s Section 125 Plan, each employee is given the opportunity to make appropriate changes to his/her Health 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 Option(s):

_______I currently participate and I wish to continue in the Health Care Spending Account.   Please deduct a total of  $_____________________*per pay period for health care expenses for the total period January 1, 20XX through December 31, 20XX.
                    *OR        Annual election amount requested  $________________.

______ I do not currently participate. I wish to start participating in the Health Care Spending Account, as of January 1, 20XX.  Please deduct a total of $____________per pay period for health care expenses for the total plan year January 1, 20XX through December 31, 20XX.
                    *OR       Annual election amount requested  $__________ .

______ I do not wish to participate in the Health Care Spending Account for Plan Year 20XX.

NOTICE:

Only those Health Care expenses that qualify are eligible for reimbursement.  Please be advised that CNM Pre-tax 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

_____________________________                          _____________________________ 
Employee Social Security #                                                                Date     

HR 12/98