PLEASE NOTE: To enroll in a flexible spending account using this form, please complete, sign electronically or manually, and return
to the Employee and Retiree Service Center (ERSC). You may fax the signed form to 301-279-3651 or 301-279-3642, or email a PDF of
the signed form to ERSC@mcpsmd.org. Please only submit your elections via one method. Submitting via multiple methods can cause errors
and delay the processing of your elections. Please visit the ERSC website for additional information. A confirmation of your elections will be sent
to you.
PART I: EMPLOYEE INFORMATION—Please print.
Name: Employee ID:
Last Four Digits of SSN: Home Phone:
You must select one of the following reasons for your account election:
o
Qualifying Event (supporting documentation required): m Marriage/Divorce m Birth/Loss of a Child m Return from Leave
m Other (i.e., change in job status, death)__________________ m COVID-19 Pandemic
PART III: SIGNATURE
I understand and acknowledge that even though I may change my election during the calendar year, I cannot decrease my
contribution to an amount less than the election I have already made. Learn about FSA rule changes made as a result of the COVID
19 pandemic at https://www.montgomeryschoolsmd.org/departments/ersc/employees/news/index.aspx?id=666201
IRS regulations impose a “use or lose” rule, requiring the forfeiture of money not used during the plan year or within the allowed
grace period.
I understand that my electronic submission of this form and my electronic signature are intended to be, constitute, and are
equivalent to my personal signature.
Signature (required) ________________________________________________________________________ Date_______________________
Medical Spending Account:
Eligible medical expenses are available at
https://www.benstrat.com/resources-forms/
Dependent/Child Care Spending Account
(Non-medical Expenses):
Eligible child care expenses are available at
https://www.benstrat.com/resources-forms/
Minimum annual contribution is $100
Maximum annual contribution is $2,750
Minimum annual contribution is $100
Maximum combined family annual contribution is $5,000
Enter your annual
contribution amount
$ .00
Enter your annual
contribution amount
$ .00
o Cancel current account: Cancels existing medical spending account
elections due to a qualifying event
o Cancel current account: Cancels existing dependent/childcare
spending account elections due to a qualifying event
Flexible Spending Account
Calendar Year 2022 Election
for Employees with a Qualifying Life Event Only
Employee and Retiree Service Center (ERSC)
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland
MCPS Form 450-3
November 2021
PART II: ACCOUNT ELECTIONS
Annual contributions are calendar year (January 1 through December 31) and are divided into equal installments over 20 pay periods
for 10-month employees or 26 pay periods for 12-month employees (see a schedule of paydays at https://www.montgomeryschoolsmd.
org/departments/ersc/employees/pay/schedules/paydays.aspx. Reminder: If you enroll outside of Open Enrollment, deductions will begin
on the first pay period from the date this form is received. Deductions will be taken in equal installments over the remaining pay periods
in the current calendar year. You may only incur expenses from the date we receive this form through the end of the extended plan year.
click to sign
signature
click to edit
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