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Signature Date Please see www. cpa125. com to download forms or for more information regarding the Flexible Spending Accounts. Cpa125. com and meet all requirements necessary to participate in the FSA Dependent Care plan. The undersigned agrees to notify the plan administrator in writing within 30 days should the undersigned no longer meet eligibility as mandated by the IRS. Dependents must qualify under IRC section 152. 848. 9848 www. CPA125. com Form must be returned to Cafeteria Plan Advisors. Fax 781. 848. 8477 Personal Information Name Employer Street Plan Year City ST Zip SSN E-Mail Phone Payroll Information I am paid Weekly IF APPLICABLE I am a Bi-Weekly Municipal Employee Semi-Monthly School Employee Monthly Other Department/Location Benefits Selected FSA Dependent/ Day Care Account FSA Medical/Dental Care Account I elect to contribute for the Plan Year. AUTHORIZATION FOR PRE-TAX PAYROLL REDUCTION Cafeteria Plan Advisors Inc* 420 Washington St* Suite 100 Braintree MA 02184 Phone 781. 5 000 maximum Confirm eligibility criteria prior to enrolling. Do not include insurance premiums. FSA Administrative Fee for the Plan Year. Direct Deposit Information Required if not on file with Cafeteria Plan Advisors Inc* I hereby authorize Cafeteria Plan Advisors Inc* to deposit my claim reimbursements directly to my bank. I also authorize drafts to adjust any over deposits that were credited to my account in error. I will contact Cafeteria Plan Advisors Inc* immediately with any bank information changes. Checking Savings Name of Bank Check Routing Number 9 digits Account Number Certification forfeited in accordance with IRS Publication 969 if eligible expenses are not submitted for reimbursement by plan year deadline or purchased utilizing the provided debit card if applicable. If terminated expenses may be incurred through termination date. Dependents must qualify under regulations set forth in IRC sections 152 and 129. Expenses must be consistent with allowable medical deductions under IRS Publication 969. This election cannot be revoked or changed during the plan year without a qualifying event as defined by the IRS* Current participants must re-enroll each plan year. Dependent Care Plan Participants only I the undersigned certify that I have read the Dependent Care Reimbursement Plan Guidelines www. 5 000 maximum Confirm eligibility criteria prior to enrolling. Do not include insurance premiums. FSA Administrative Fee for the Plan Year. Direct Deposit Information Required if not on file with Cafeteria Plan Advisors Inc* I hereby authorize Cafeteria Plan Advisors Inc* to deposit my claim reimbursements directly to my bank. Direct Deposit Information Required if not on file with Cafeteria Plan Advisors Inc* I hereby authorize Cafeteria Plan Advisors Inc* to deposit my claim reimbursements directly to my bank. I also authorize drafts to adjust any over deposits that were credited to my account in error. I will contact Cafeteria Plan Advisors Inc* immediately with any bank information changes.

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