Flexible Benefit Cafeteria Plan

SCHOOL DISTRICT OF WESTFIELD

N7046 CTY ROAD M WESTFIELD, WI 53964 PH: 608-296-2141  FAX: 608-296-2938

CAFETERIA PLAN ELECTION AGREEMENT

Plan Year from July 1, 2017 – June 30, 2018

Name (please print) ______

HEALTH FLEXIBLE SPENDING ACCOUNT (HEALTH FSA)

______I hereby ELECT to participate. $______(Annual Amount) (Not to exceed $2,600 if head of household or married filing jointly, $1,300 if married filing separately) Annual Amount elected will be equally divided into 26 paychecks for staff paid on 26 payrolls. Annual Amount elected will be equally divided into 20 paychecks for school year support staff.

______I hereby elect not to participate.

DEPENDENT CARE ASSISTANCE PLAN (DCAP)

______I hereby ELECT to participate. $______(Annual Amount) (Not to exceed $5,000 if head of household or married filing jointly, $2,500 if married filing separately) Annual Amount elected will be equally divided into 26 paychecks for staff paid on 26 payrolls. Annual Amount elected will be equally divided into 20 paychecks for school year support staff.

______I hereby elect not to participate.

Date: ______Employee Signature: ______

IF THE DISTRICT OFFICE DOES NOT RECEIVE AN ENROLLMENT FORM FROM YOU BY MAY 31ST, YOU WILL NOT BE ENROLLED IN THE HEALTH FSA OR DCAP FOR THIS PLAN YEAR