HR FSA Plan Document

HR FSA PLAN DOCUMENT

Employer and Plan Identification

Employer Name:

Plan Year Begin:    Plan Year End:

Definitions

Participant means an employee who meets the eligibility requirements set forth in this Plan and who has properly enrolled. Dependent means an individual who meets the definition of dependent for purposes of reimbursement under the Health Care FSA or Dependent Care FSA.

Qualified Medical Expenses means expenses defined under applicable tax rules as eligible for reimbursement through a Health Care Flexible Spending Account. Eligible Dependent Care Expenses means day care and related expenses permitting the employee (and spouse if applicable) to work or look for work.

Eligibility and Participation

Eligibility: All employees classified as eligible by the employer are eligible to participate after completing the waiting period specified below. Waiting period (if any):

Participation becomes effective on the first day of the payroll period following the employee's date of hire or following the completion of the waiting period as determined by the employer.

Elections, Contributions and Payroll Deductions

Employee Election for Health Care FSA (annual): $. Payroll deduction frequency:

Employee Election for Dependent Care FSA (annual): $. Employer contributions, if any: $

Election Changes and Qualified Events

Elections are generally irrevocable for the plan year except in the case of a qualifying change in status. Qualifying events include marriage, divorce, death of a spouse or dependent, birth or adoption of a child, change in employment status, or other events recognized under applicable law.

To request a mid-year election change, the participant must notify the Plan Administrator and submit evidence of the qualifying event within of the event.

Claims, Substantiation and Reimbursements

Claims for reimbursement must be submitted on the forms or by the methods prescribed by the Plan Administrator. Each claim must include documentation establishing that the expense is a qualified expense. Claims submission method:

The Plan reserves the right to deny claims that are not properly substantiated or that do not meet Plan requirements. Reimbursement will be made by check or direct deposit as determined by the Plan Administrator.

Carryover, Grace Period and Forfeitures

The Plan's treatment of unused amounts at year-end is selected by the employer below. Select one:

Allow carryover of up to $ to the next plan year.

Allow a grace period of after plan year end for claims run-out.

Forfeitures of unused amounts will be administered in accordance with Plan provisions and applicable law.

COBRA and Continuation Coverage

Participants and qualified beneficiaries may be entitled to continuation coverage in accordance with applicable law. Election and premium procedures will be provided by the Plan Administrator in writing at the time of a qualifying event.

Claims Review and Appeals

The Plan establishes an administrative claims review and appeal process. A denied claim may be appealed in writing to the Plan Administrator within days of notice of denial. The appeal will be reviewed and a determination provided within a reasonable period consistent with applicable law.

Amendment and Termination

The Employer reserves the right to amend, modify, or terminate the Plan at any time, provided that no amendment will reduce accrued rights to amounts already reimbursed or create additional liability for participants beyond amounts contributed and available under the Plan, except as permitted by law.

Administrator and Fiduciary Responsibilities

The Plan Administrator is responsible for plan administration, recordkeeping, and participant communications. Fiduciaries shall discharge their duties solely in the interest of participants and beneficiaries and in accordance with applicable fiduciary standards.

Tax Treatment and Compliance

Contributions to the Health Care and Dependent Care FSAs are made on a pre-tax basis as permitted by applicable federal tax rules. Participants are responsible for the tax consequences of their elections and should consult their personal tax advisor for guidance.

Participant Enrollment and Employee Information

Position Information

Date of Hire:    Current Salary: $

Employment History (Most Recent 2 Employers)

Education

Graduation Date:

Professional References (3)

Legal Disclosures

At-Will Employment: Participation in the Plan does not alter the at-will employment relationship between the employee and the employer. Either the employee or the employer may terminate the employment relationship at any time with or without cause or notice, unless a separate written agreement states otherwise.

Equal Opportunity: The employer is an equal opportunity employer. Participation in the Plan will be administered without regard to race, color, religion, sex, national origin, age, disability, or any other protected characteristic.

Participant Certification and Authorizations

I certify that the information I provided on this Enrollment and Participant Information section is true and complete to the best of my knowledge. I understand that false statements may result in denial of benefits and may constitute grounds for disciplinary action.

I authorize the Employer and Plan Administrator to deduct from my wages the amounts necessary to fund my elections under this Plan and to use my payroll data for Plan administration. I also authorize the Plan Administrator to contact my previous employers for verification of employment information where permitted by law.

I certify that all information provided is true and complete and that I have read and understand the Plan terms described in this document.

I authorize the Employer and Plan Administrator to contact previous employers and references for purposes of verification and background screening as necessary for Plan administration.

Notice and Privacy

The Plan Administrator will maintain records and may use and disclose personal information to the extent necessary for Plan administration, in accordance with applicable privacy rules. Participants should direct privacy inquiries to the Plan Administrator at the address provided above.

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