07-D TML Health Reimbursement Acct

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TML Intergovernmental Employee Benefits Pool PO Box 140167 Austin, Texas 78714-0167 Fax: (512) 719-6505 IITML t41 Intergovernmental Employee Benefits Pool EMPLOYEE ENROLLMENT FORM Employer Name Employer Group # Employee Name Social Security # Street Address City State Zip Code D Check here if new Date of Birth Check One Check One Date Employed D Male D Single D Widowed D Female D Married D Divorced Spouse Name (First, M.I.) Date of Birth I request that my salary be reduced as follows: I I Annually Monthly Dependent Name (First, M.I.) Date of Birth Contribution for Medical Coverage $ $ I I Contribution for Dental Coverage $ $ Dependent Name (First, M.l.) Date of Birth Other Contributions (SPECIFY) I I $ $ Dependent Name (First, M.I.) Date of Birth I I Unreimbursed Health Care Expenses $ $ Dependent Name (First, M.I.) Date of Birth Dependent Care Expense $ $ I I Total Authorized Reductions $ $ AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that any children listed are dependents under Section 152 of the Internal Revenue Code. I understand that any amounts remaining in my account(s) not used for expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws. I also understand that the Flexible Spending reduction(s) will be in effect for the plan year and cannot be revoked unless I experience a change in my family status, significant change in cost or coverage of my health plan or my spouse's health plan or separation from service as prescribed by IRS rules. If a change in family status occurs, you have 31 days from the occurrence to change or revoke your election. Furthermore, I hereby authorize my employer to transfer my required health benefits contribution on a monthly basis to the TML Intergovernmental Employee Benefits Pool. Employee Signature Date IF YOU DECLINE PARTICIPATION: The benefits of the plan have been thoroughly explainedto me and I decline to participate. Dilte CONFIDENTIALITY NOTICE: The information contained in this transmission, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure, or distnbution is prohibited by Federal law. If you are not the intended recipient of this message, you are notified that you may not disclose, print, copy, or disseminate this information. If you have received this transmission in error, please reply to the sender and delete or destroy the message. Unauthorized interception of this transmission may be a violation of criminal law