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Wauwatosa School District Contribution Form

Limited Purpose Flexible Spending Account (LP-FSA)

October 1, 2020 - September 30, 2021

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I hereby make the following FSA election, to be effective on the next permissible payroll check (HSA elections should be made on a separate HSA Enrollment Form):

Current Signature

I have received and have read the materials given to me explaining the Flexible Spending Account plan.  I understand that my decision regarding this election is effective through the last day of the plan year.  Unless I have a change in family status, and I notify the Human Resources Department of this change within 30 days, there is no change permitted in the election made today.  I also understand that I must complete and submit a new election form in order to make similar contributions in future years.

I authorize the District to reduce my salary by the amount indicated above to pay for the benefits I have elected, and I understand that I will forfeit any unused balance in my account at the end of the plan year for the FSA account.  Although I intend to make the elected contributions on a pre-tax basis, I acknowledge that the District may decide that it needs to limit or reduce my contributions in the future.