2011 Flexible Spending Accounts Enrollment
                 Orange County Community College Section 125 Flexible Benefit Plan 
           Plan Year Coverage 01/01/11 � 12/31/11          


Name (print) 							Social Security Number________/______/_______	

Mailing  Address 												
                                Street or PO Box                                  City                                     State                    Zip Code

I hereby elect to make an annual contribution to the flexible spending account(s) under the Plan and agree that the annual contribution will be made in equal amounts each pay period through payroll deduction. (There are 26 pay periods if a full year; for new employees entering after January 1, 2011, the number of pay periods will vary.) Check the applicable account/s.


     1.  (   ) HEALTH CARE FLEXIBLE SPENDING ACCOUNT (Health FSA � IRS 125) $ _____________ total for the plan year. 
                       The minimum annual deposit in the Health Care Flexible Spending Account is $300 and the maximum cannot exceed $3,000.

     2.  (   ) DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (IRS 129) $_____________________ total for the plan year.
                  The minimum annual deposit in the Dependent Care Flexible Spending Account is $300 and the maximum cannot exceed $5,000. ($300 minimum and $2,500 for married participants who file separate returns.)

DEPENDENT(S) INFORMATION
HEALTH
FSA 


DEP
CARE

LAST NAME

FIRST NAME

M/F

DATE OF BIRTH

RELATIONSHIP

































































I agree that my compensation will be reduced by the amount of my required contribution for the benefits I have elected under the Orange County Government Section 125 Flexible Benefit Plan, and that such salary reductions will continue for each pay period until this agreement is amended or terminated.  I understand that:


* I cannot change or revoke this Salary Reduction Agreement as of any date prior to the next Plan Year, unless a Change in Status, as permitted under the Internal Revenue Code, occurs.  Documentation consistent with this request must be provided.

* Salary Reductions under this Salary Reduction Agreement will reduce my compensation for Social Security tax purposes.   

* Eligible expenses must be incurred by 12/31/11.  Claims must be submitted on or before 3/31/12. Unused funds will be forfeited.

* If I do not complete and return a new election form during next Open Enrollment, my participation in the Flexible Spending Program will terminate December 31, 2011.

* If I am enrolled in a Health FSA, and go out on a Leave of Absence, or separate from employment, I must notify Risk Management.



	       _____________________________________________				______________________
                       Signature of Participant							      Date
       
	             Revised    10/10