ABRAHAM BALDWIN AGRICULTURAL COLLEGE

FLEXIBLE SPENDING ACCOUNT ELECTION FORM

I have read the Abraham Baldwin Agricultural College Flexible Spending Accounts policy.  I understand that I have the option to reduce my salary to reimburse myself for Unreimbursed Health Care expenses and/or Dependent Care expenses I may incur in the coming year.  I have indicated by how much I wish to reduce my salary for the period January 1, 2009 through December 31, 2009.

SALARY REDUCTION FOR DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT

I understand that I may elect to reduce my salary by up to $5,000 per year for the Dependent Care Flexible Spending Account for the plan year ending December 31, 2009.  NOTE:  ANY AMOUNT DEDUCTED DURING THE PLAN YEAR FOR WHICH CLAIMS ARE NOT MADE WILL BE FORFEITED.

□    I elect no salary reduction for the plan year ending December 31, 2009.           ___________

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□    I elect to reduce my salary by ______________ per year.                                 ___________               

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SALARY REDUCTION FOR HEALTH CARE FLEXIBLE SPENDING ACCOUNT

I understand that I may elect to reduce my salary by up to any amount per year for the Unreimbursed Health Care Flexible Spending Account for the plan year ending December 31, 2009.  NOTE:  ANY AMOUNT DEDUCTED DURING THE PLAN FOR WHICH CLAIMS ARE NOT MADE WILL BE FORFEITED.

□    I elect no salary reduction for the plan year ending December 31, 2009.              __________

                                                                                                                                         INITIALS

□    I elect to reduce my salary by _______________ per year.                                   __________

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I understand that I will not be permitted to change my election(s) until the next open enrollment date, except for the following changes in circumstances:

·         Marriage or Divorce

·         Birth, Adoption or Death of a Child

·         The Death or Change in Employment Status of my Spouse

I understand further that any change I request because of these changes in family circumstances or status must be consistent with that change.  Finally, I understand that if I should terminate employment before the end of the plan year, my salary reduction will cease to be effective on the day I terminate my employment with Abraham Baldwin Agricultural College.

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Print or Type Name                                                                                                                Social Security #

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Signature                                                                                                                       Date