2026 Flexible Spending Account Election Form For:

I understand that reimbursement will only be available for Eligible Dependent Care and Medical/Dental/Vision Expenses and agree to notify the Employer if I have reason to believe that any expense for which I have received reimbursement is not so qualified. I also agree, upon demand, to indemnify and reimburse the employer for any liability it may incur for failure to withhold federal or state income taxes or FICA taxes from any reimbursement I receive for non-qualifying expenses, up to the amount of additional tax owed by me. This election form revokes any prior election form completed and will remain in effect and cannot be revoked or changed during the plan year, unless the revocation and new election are on account of, and consistent with, a change in family status (i.e. marriage, divorce, death of a spouse/child, birth or adoption of a child, or termination of employment of spouse). Participation in this plan will automatically cease upon termination of employment. However, rights to continue participation will be provided within 14 days of termination as specified under the consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).