| Sample Flexible Spending Account (FSA) Plan Document |
| with pdf form agreement for salary reduction |
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Handle:
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Document-932
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Owner:
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Finance Office (User-16, fit:DocuShare)DS
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| Friday, September 8, 2006 03:58:26 PM CDT |
| Friday, December 21, 2007 08:39:30 AM CST |
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Modified By:
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Finance Office (User-16, fit:DocuShare)DS
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Locked By:
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| - 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 ...
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| Allowed |
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Adobe Portable Document Format (.pdf) - application/pdf
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| sample flexible spending account plan document.pdf |
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| 4 |
| 101027 |
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| No |
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Appears In:
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Health Reimbursement Plans
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New Employee Documents - Forms needed for new hires
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Preferred Version:
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Salary Reduction Agreement for FSA, MRF, & HSA use only
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Finance 
