2017-18

Wauwatosa School District Contribution Form Limited Purpose Flexible Spending Account (LP-FSA) Elections from October 1, 2017 – September 30, 2018

 Change in Family Status/Qualifying Event

 Initial Enrollment/Annual Election

_________________________________________________________________

Effective Date of Change in Family Status /Qualifying Event Participant’s Name:

Date of Birth: ___________________

Email Address: _____________________________________________ (preferably non district email) Street Address:

Social Security Number:

___________________________________________________________ ___________________________________________________________ ___________________________________________________________ City

__________ State

____________________ Zip

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):

Dependent Care FSA Maximum Allowable Annual Contribution: $5,000 per family My Annual Election: $________________________

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 is not responsible for the tax treatment of my contributions. I also acknowledge that the District may decide that it needs to limit or reduce my contributions in the future. ___________________________________________________________________

Participant’s Signature

_____________________________________

Date