PENN STATE FLEXIBLE BENEFIT ELECTION FORM

NAME____________________PSU ID #__________________PHONE(____)__________

HEALTH CARE REIMBURSEMENT ACCOUNT

Out-of-pocket medical, dental, and vision expense for faculty/staff and dependents.  For guidance on eligible and ineligible expenses, please refer to the Flexible Benefits information on line at /benefits/flex/index.htm.

(   )    I elect to participate and my authorized contribution from my PRETAX salary for EACH PAY PERIOD is $_______.____

NOTE: Do not enter the amount of the annual contribution

(   )    I elect NOT to participate

DEPENDENT CARE REIMBURSEMENT ACCOUNT

Work-related daycare, nursery school, elder care, etc. NOT for dependents medical expenses. For guidance on eligible and ineligible expenses, please refer to the Flexible Benefits information on line at /benefits/flex/index.htm.

(   )      I elect to participate and my authorized contribution from my PRETAX salary for EACH PAY PERIOD is $_______.___

NOTE:  Do not enter the amount of the annual contribution

(   )    I elect NOT to participate

DEPENDENT DATA

INSTRUCTIONS: This section is to be completed ONLY if you have elected one or both of the Reimbursement Accounts and will be submitting expenses incurred by your dependents. For this purpose, please consider your spouse a dependent and list him/her first followed by any children or other dependents.

CERTIFICATION/SIGNATURE

I have indicated my benefit elections for this calendar year in the appropriate sections. I understand that I may change my elections only during the Annual Election Period or in the event of a change in family status as defined in the FLEXIBLE BENEFITS information on line at /benefits/flex/index.htm and as outlined in the section below.

I understand that:

• Reimbursement Account elections do not renew automatically each year
• Participation in any future year will require a new election to be completed during the appropriate election period
• Reimbursements may be made only for eligible expenses incurred during the Plan Year regardless of when payment was made
• Reimbursements are subject to IRS regulations
• If I do not apply for the reimbursement of the full amount of my contributions before the end of the Grace Period, I will forfeit the unused balance.

Signature___________________________________

Date_________________________

CERTIFICATION OF CHANGE IN FAMILY STATUS

The Penn State Flexible Benefits Plan, in accordance with the Internal Revenue Code, requires your Flexible Benefit Elections to remain in force for the entire year unless you experience a change in family status. Those qualified changes are listed below. If you have experienced a change in family status and desire to change your level of participation, complete this certification below and make the appropriate deduction amount changes on the front of this form. This form must be signed, dated and received by Employee Benefits within 60 days of the event.

All changes must be on account of and consistent with the change in family status event.

I am requesting a change in my Flexible Benefit Election for the Plan Year ____.  The date of the change in family status event that prompts this request is ________________________.

Check the appropriate event:

1. (   )  Your marriage
2. (   )  Birth or adoption of child(ren)
          Name______________________________________
3. (   )  Death of spouse or a dependent
          Name____________________________  Relationship__________________________
4. (   )  Your divorce (actual divorce not separation)
5. (   )  Termination or commencement of spouse's employment
           (Valid only if health benefits provided by spouse's employer begin or end as a result of the change.)
6. (   )  Change in your Dependent Care costs only if currently enrolled
           From_______________________________        To________________________

CERTIFICATION AND SIGNATURE FOR CHANGE IN FAMILY STATUS

I acknowledge that if I am ending my participation in any reimbursement account, reimbursements will be limited to expenses incurred before the date of this form. If I am electing a reimbursement account in which I did not previously participate during this Plan Year, reimbursements will be limited to expenses incurred after the date of this form. I understand that the favorable tax treatment under the Penn State Flexible Benefit Plan is dependent upon the accuracy of my statements. I certify that the information, events and dates indicated are accurate and truthful.

Signature____________________________________            Date_________________________

MAIL COMPLETED FORM TO EMPLOYEE BENEFITS DIVISION, JAMES M. ELLIOTT BUILDING, UNIVERSITY PARK, PA 16802.