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Sample Flexible Spending Account (FSA) Plan Document
with pdf form agreement for salary reduction
Handle: Document-932
Owner: Finance Office (User-16, fit:DocuShare)DS
Friday, September 8, 2006 03:58:26 PM CDT
Friday, December 21, 2007 08:39:30 AM CST
Modified By: Finance Office (User-16, fit:DocuShare)DS
Locked By:
  • I understand and agree as follows:1.
  • This amount will be deducted from my regular paychecks.2.
  • If my pay for any period is insuf?cient to cover a deduction, a partial deduction will be made.3.
  • I can be reimbursed only for quali?ed expenses incurred during the plan year (_____________ to _____________) or until participation ends.4.
  • If I terminate employment, my participation in my healthcare FSA ceases unless I elect to have my ?nal pay reduced to fund my healthcare FSA.5.
  • This authorization is ...
Adobe Portable Document Format (.pdf) - application/pdf
sample flexible spending account plan document.pdf
Appears In: Health Reimbursement Plans New Employee Documents - Forms needed for new hires
Preferred Version: Salary Reduction Agreement for FSA, MRF, & HSA use only