2007 Flex Change Form

DIOCESEOFWINONA

FLEXIBLEBENEFITSSTATUSCHANGEFORM

PlanYear:July01–June30StatusChangeEffectiveDate:

YoumaychangeyoursalaryreductionandallocationofbenefitsduringtheplanyearonlyifyouexperienceaCHANGEINFAMILYSTATUS.AnychangeinsalaryreductionorallocationofbenefitsmustbeconsistentwiththeChangeinFamilyStatusyouhaveexperienced.Pleasechecktheappropriateboxbelowtoreflectyourchangeinfamilystatusandwritethedateofthechangeinthelineprovided.

THISFORM MUST BE SUBMITTEDTOTHEPLANADMINISTRATORWITHIN 30 DAYSOFTHESTATUSCHANGEEVENT.

Marriage: Divorce: Deathofadependent:

Achildisbornoradopted:

Adependentchildreachesthecoveragelimitoftheplan: Changeinemploymentstatusforspouseoremployee: Yourspousecommencesorterminatesemployment: Unpaidleaveofabsencebyemployee:

Other

EmployeeName:SocialSecurity#:

EMPLOYEEINFORMATION:

(Completeifthisinformationifchangingorifyouareenteringtheplanforthefirsttime.)

Namechangeto: Address:

FlexibleSpendingAccount–HealthCare

NewPlanYearElection:$ DiscontinueParticipation

(Minimum$100,Maximum$3,000perPlanYear)

GrouporindividualinsurancepremiumsarenotaneligibleexpenseundertheHealthCareFlexibleSpendingAccount.

FlexibleSpendingAccount–DependentCare

NewPlanYearElection:$ DiscontinueParticipation

(Minimum$100,Maximum$5,000perPlanYearor$2,500ifmarriedbutfilingseparately)

ENROLLMENTAUTHORIZATION:

Iunderstandthebenefitoptionsandrequirementspresentedtherein. IamenrollingfortheeligiblebenefitsIindicateintheCOVERAGEsectionandIauthorizereductionsfrommyearnings. I understandandagreethatifmyeligibleexpensesdo notreachthe amount I haveallocatedtothatbenefit,Iwill forfeitanyamountsremaininginmyparticipant accountat theend ofthePlanYear. Iassumethisriskofforfeitureofmoneysremaininginmyflexaccounts. Ialsounderstandthatall expensesforwhichIseekreimbursement mustbeforservicesperformedduringthePlanYearandwhileIamaparticipantintheFlexibleBenefits Plan.I understandpaymentsforReimbursementAccountswill bemadedirectlytome. IunderstandthatIcannotreviseorrevokethisEnrollmentAuthorizationorinanywaychangetheamountsdeductedfrommysalaryduringthePlanYear, exceptwherethechangeisconsistent withafamilystatusasdefinedinthe FlexibleBenefitsPlan. IagreetoobservethetermsandconditionsoftheFlexibleBenefitsPlanandallrulesandregulationsestablishedbytheCompany toadministerthePlan.IunderstandthattheEmployercannotbe heldresponsibleforthetaxconsequenceswhichmayormay notresultfromthebenefit(s)I haveselectedabove. ThisplanisregulatedbyInternal RevenueCodeSections105,125,and129,andissubjecttodiscriminationregulations. Intheeventthattheplanisfoundtobeoutofcompliancewithdiscriminationrules,Imayberequiredtoreduceoreliminatemypre-taxdeductionelection.

CorporateHealthSystems,Inc.

POBox46850

EdenPrairie,MN55344-6850

Phone:(952)939-0911 Fax:(952)939-0990

EMPLOYEESIGNATUREDATE

(Office Use Only)

Parish/School:PayrollType:

BenefitAdministrator:Date:_

10/2007D-4