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.