SLETTO & ASSOCIATES, P - CHG Healthcare Services

K.4. For Medical Reimbursement Expense, Dependent Care and Adoption Assistance Spending Account
reimbursements, Participants must file Benefit claims… [check one]:
a. Not applicable [No Benefit is allowed]
b. Within days after Plan Year end for expenses incurred in the current Plan Year
c. By March 31 [enter Month and day] of the following Plan Year for expenses incurred in the current
Plan Year
d. Other [specify]:
K.5. The applicable Grace Period for Medical Reimbursement Expense, Dependent Care, and Adoption Assistance
Spending Account reimbursements will be… [check one](not to exceed the time period in K.5.b):
a. Not applicable [No Benefits is allowed]
b. The fifteenth day of the third month following the end of the Plan Year
c. Sixty days after the end of the Plan Year
d. Thirty days after the end of the Plan Year
e. Other [specify]:
K.6.
Spending Account Forfeitures shall be reallocated during the following Plan Year as follows… [check one]:
a. Not applicable
b. Pro-rata by Eligible Participant
c. Used to reduce Employer Contributions
d. Added to Employer Contributions
e. Other [specify]: Used to defray administrative expenses.
K.7. An Employee who becomes ineligible to participate in the plan with an unused salary reduction amount in their
Dependent Care Spending Account will… [check one]:
a. Forfeit the account balance to the Forfeiture Surplus Account.
b. be allowed to “spend down” those funds as long as they satisfy IRC §129.
ADOPTION AGREEMENT
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FLEXIBLE BENFITS PLAN