Participation Form for Flexible Benefits Plan

(New application must be completed each year)

Plan Year Effective January 1, 2013 through December 31, 2013

Employer Name Forsyth County Board of Education

Employee Name ______

Social Security Number ______Date of Birth______

Home Address ______

Street City State Zip Code

Home Phone ( )______School Location ______

Requested Effective Date: January 1, 2013 Paycheck Frequency: Monthly

Option I: Healthcare Reimbursement Account Agreement

_____Yes I elect to contribute $______(before taxes) per pay period, which is $______per plan year, (minimum deduction of 25.00 per month, not to exceed $2,500 per plan year) to fund my account for reimbursement of qualified out of pocket healthcare expenses not covered under my health and other insurance plans.

_____No I decline this option for this plan year and understand that I will lose all tax savings that I could receive as a participant.

Option II: Dependent Daycare Reimbursement Account Agreement for Eligible Children and Adults.

_____ Yes I elect to contribute $______(before taxes) per pay period, which is $______per plan year, for funding reimbursement of qualified dependent daycare expenses. (Maximum amount per calendar year is the lesser of; (1) $5,000 for married filing joint, or $2,500 for married filing separate; (2) your spouse’s total amount compensation; or (3) ½ of your total annual compensation. If you are single, the maximum amount is $5,000.)

_____ No I decline this option for this plan year and understand that I will lose all tax savings that I could receive as a participant.

Option III: Agreement to Save Taxes on Insurance Premiums

_____Yes On the appropriate benefit enrollment form, I have enrolled in certain employer-sponsored insurance benefits (i.e. health insurance). I understand that my share of the premium for these employee benefits will automatically be paid with pre-tax dollars. I also understand that if my required contributions for these insurance benefits are increased or decreased while this agreement is in effect, my taxable income will automatically be adjusted to reflect that change.

_____No I decline this option for this plan year and understand that I will lose all tax savings that I could receive as a participant.

My employer and I agree that my taxable income will be reduced each pay period during the year by an equal portion of the benefit elections ( 1 thru 3) set forth above and that qualified expenses will be paid on a tax-free basis. I understand that I may change my election in the event of certain changes in my status and that, prior to the first day of each plan year, I will be offered the opportunity to change my benefit election for the upcoming plan year. I acknowledge that I have received, read and understand the Summary Plan Description.

Employee Signature ______Date ______