Flexible Spending Account (FSA)

Valuable pre-tax benefits with convenient tools

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Pre-Tax Savings Example Without FSA With FSA

Gross Monthly Pay: $3,500 $3,500Pre-Tax ContributionsMedical/Dental Premiums $0 -$125Medical Expenses $0 -$75Dependent Care Expenses $0 -$400TOTAL: $0 -$600Taxable Monthly Income $3,500 $2,900Taxes (federal, state, FICA): -$968 -$802Out-of-pocket Expenses: -$600 $0Monthly Take-home Pay: $1,932 $2,098

Net Increase in Take-Home Pay = $166/mo!For illustration only. Actual dollar amounts may vary.

Carryover puts your mind at ease! When your employer elects the Carryover option with your Healthcare FSA Plan, up to $500 of any leftover healthcare funds may be carried over into the next Plan Year with no cost or penalty.

Why not use pre-tax dollars to pay for medical co-pays, prescriptions, and/or daycare fees, thereby reducing your taxable income and increasing your take-home pay? It's a no-brainer.

The pre-tax advantages of a Flexible Spending Account (FSA) allow you to save up to 30% on your eligible healthcare and/or dependent care expenses every year. Consider how much you spend on these costs for you and your qualified dependents in one year and how much you could save by using pre-tax dollars.

How it WorksFlexSystem FSA is offered through your employer and is administered by TASC. When you choose to enroll in a FlexSystem Healthcare and/or Dependent Care FSA, you determine the dollar amount you want to contribute to each account based on your estimated expenses for the upcoming Plan Year. Your contributions will be deducted in equal amounts from each paycheck, pre-tax, throughout the Plan Year.

The more you contribute to these accounts, the more you reduce your taxable gross salary. And with less taxes taken, your take-home pay increases!

Your total annual Healthcare FSA contribution amount is available immediately at the start of the Plan Year. Dependent Care FSA funds are available up to the current account balance only.

Online Enrollment and ContributionsAnnual FSA contributions are set by your employer, but are limited to the IRS maximums per Plan Year. View current IRS limits at: www.tasconline.com/biz-resource-center/benefits-limits/

Use our online tax-savings calculator to help determine how much you should contribute to each FlexSystem account per year.

The TASC Card ConvenienceEnjoy easy access to your FSA funds with the swipe of a card instead of out-of-pocket spending and requesting a reimbursement!

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Step 1: Choose the FlexSystem Account(s) To enroll in FlexSystem FSA, you must first choose which Flexible Spending Account(s) you wish to participate in for the Plan Year (as offered by your employer). The options may include:

• Healthcare FSA• Dependent Care FSA• Non-Employer Sponsored Premiums (NESP)

Step 2: Determine Your FSA Election Amount(s)Next, determine your annual elections to be contributed pre-tax into each type of FSA from your payroll over the course of the Plan Year. Your elections are specific to each FSA and may only be used for expenses incurred for that account type. For example, dollars set aside for Dependent Care FSA may only be used for dependent care expenses and not for healthcare expenses. Calculate your potential savings with our online FSA calculator!

How to Enroll

Step 3: Complete Enrollment Form (online or paper)Before your begin, obtain the TASC Employer ID# from your employer, as you will need to enter it on the enrollment form. Choose to enroll online or via paper form and follow the instructions below:

Online Enrollment (recommended) Online enrollment into FlexSystem FSA is easy, secure, and available 24-hours a day from the convenience of your home. Go to:www.tasconline.com/tasconline/flexsystem/enroll

New Enrollees (new to the Plan):Go to New Account Setup - enter the Employer ID# and establish your personal username and password. A valid email address is required to authenticate your account. Once you have authenticated your account, simply follow the system prompts to enroll.

Renewing Enrollees:Enter your 12-digit TASC ID# and password. Click Submit and Continue and follow the on-screen enrollment prompts.

Paper Enrollment Form A paper enrollment form is available from your employer. Complete the one-page form and refer to the instructions on page two of the form as needed. Please sign and date the completed form and return it to your employer for processing.

Step 4: Success!Once your enrollment is processed, you will receive the Welcome New FlexSystem Participant email from TASC with account access instructions to begin using and managing your FlexSystem account(s) online. And your TASC Card(s) will be mailed to your home address within 7-10 business days and ready to use for eligible expenses!

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Simple steps for enrollment into the FlexSystem FSA Plan

• Transit Reimbursement Account• Parking Reimbursement Account

Need more help?Watch our

online enrollment video

Total Administrative Services Corporation2302 International Lane I Madison, WI 53704-3140

Below is a partial list of permissible expenses reimbursable through a Flexible Spending Account (FSA) that are incurred by you, your spouse, or qualified dependents. Please note: a Limited Purpose Healthcare FSA only allows dental and vision expenses.

Eligible and Ineligible Expenses for FSA

Expenses that qualify for reimbursement from FlexSystem

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Healthcare FSA | Dependent Care FSA

Medical Expenses • Acupuncture• Artificial limbs• Bandages• Birth control, contraceptive devices• Birthing classes/Lamaze – only the mother’s portion

(not the coach/spouse) and the class must be only for birthing instruction, not child rearing

• Blood pressure monitor• Blood sugar test kits/test strips• Chiropractic therapy/exams/adjustments• Contact lens and contact lens solutions• Co-payments• Crutches (purchased or rented)• Deductible and co-insurance• Diabetic supplies• Eye exams• Eyeglasses, contacts, or safety glasses, prescription

only (warranties are not reimbursable)• Flu shots • Hearing aids and hearing aid batteries (warranties

are not reimbursable)• Heating pad• Incontinence supplies • Infertility treatments• Insulin• Lactation expenses (breast pumps, etc.)• Laser eye surgery; LASIK• Legal sterilization• Medical supplies to treat an injury or illness• Mileage to and from doctor appointments• Nasal strips• Optometrist’s or ophthalmologist’s fees• Orthopedic inserts• Physicals• Physical therapy (as medical treatment)

• Physician’s fee and hospital services• Pregnancy test• Prescription drugs and medications• Psychotherapy, psychiatric and psychological service• Reading glasses• Sales tax on eligible expenses• Services connected with donating an organ• Sleep apnea services/products (as prescribed)• Smoking cessation programs• Treatment for alcoholism or drug dependency• Vaccinations• Wrist supports, elastic wraps• X-ray fees

OTC Medicines and DrugsOver-the-counter (OTC) medicines and drugs, except for insulin, require a prescription from your physician to be reimbursable. The prescription will need to be included with each request for reimbursement.

• Bengay, Flexall, pain relieving creams or gels• Calamine lotion• Canker/cold sore relievers• Cold medicines• Corn removal• Diaper rash ointment• GasX, baby gas drops• Hemorrhoid creams and treatments• Hydrogen Peroxide or rubbing alcohol• Indigestion or anti-acid relievers• Laxatives• Nicotine patch• Pain relievers (Tylenol, Advil, Aspirin, etc.)• Sinus medicines• Suppositories• Teething gel• Wart removal medication

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Total Administrative Services Corporation2302 International Lane I Madison, WI 53704-3140

For more information regarding FSA expenses, please review IRS Publication 502 or ask your employer for a copy of your Summary Plan Description (SPD).

Dental Expenses• Braces and orthodontic services • Cleanings• Crowns• Deductibles, co-insurance• Dental implants• Dentures, adhesives• Fillings

Disability Expenses• Automobile equipment and installation costs for a

disabled person in excess of the cost of an ordinary automobile; device for lifting a mobility impaired person into an automobile

• Braille books/magazines in excess of cost of regular editions• Note-taker for a hearing impaired child in school• Seeing eye dog (buying, training, and maintaining)• Special devices, such as a tape recorder or typewriter for

a visually impaired person• Visual alert system in the home or other items such as a

special phone required for a hearing impaired person• Wheelchair or autoette (cost of operating/maintaining)

Requiring Additional DocumentationThe following expenses are eligible only when incurred to treat a diagnosed medical condition. Such expenses require a Letter of Medical Necessity from your physician, containing the medical necessity of the expense, diagnosed condition, onset of condition, and physician’s signature.

• Ear plugs• Massage treatments• Nursing services for care of a special medical ailment• Orthopedic shoes (excess cost of ordinary shoes)• Oxygen equipment and oxygen • Support hose • Varicose vein treatment• Veneers• Vitamins and supplements• Wigs (for mental health condition of individual who loses

hair because of a disease)

Dependent Care Expenses• Fees for licensed day care or adult care facilities• Before and after school care programs for dependents

under age 13• Amounts paid for services (including babysitters or nursery

school) provided in or outside of your home• Nanny expenses attributed to dependent care • Nursery school (preschool) fees• Summer Day Camp – primary purpose must be custodial

care and not educational in nature• Late pick-up fees• Does not cover medical costs; use Healthcare FSA for

medical expenses incurred by you or your dependents

Ineligible Medical Expenses• Athletic mouth guards• Chapstick/lip balm• Contributions to state disability funds• Cosmetic surgery, dentistry, or other cosmetic procedures• Cosmetic supplies (makeup, cleansers, moisturizers, etc.)• Deodorant• Dental floss• Diet (cost of special foods as substitute for regular diet)• Dietary and fiber supplements• Electrolysis/hair removal• Exercise equipment and fees• Eye drops for general comfort• Eyeglass cases• Hand sanitizer• Health club or athletic club membership fees• Herbal supplements• Insurance premiums, all types• Lotions or skin moisturizers• Marriage counseling• Maternity clothes• Mattress• Medicare premiums• Medicated shampoos, conditioners, and soaps• Physical treatment unrelated to specific health problems (massage for general well-being, stress, depression, or chiropractic wellness)• Safety glasses (non-prescription)• Sunglasses (non prescription) and sun clips• Teeth whitening products• Toiletries• Toothbrush (includes prescribed electronic) and toothpaste• Vitamins and supplements for well-being• Warranties• Weight loss drugs/programs for general well being

FlexSystem Features

• TASC Card pays for and substantiates most eligible expenses at the point of purchase.

• Reimbursements are deposited in MyCash and accessible via the TASC Card.

• Mobile App, texting, and 24-hour phone system for easy access on the go!

• Convenient account management, including online reimbursement requests.

• Dedicated customer support team.

Putting money in an FSA is smart and safe. Everybody has medical bills, right? Expenses for prescriptions, co-pays, doctor’s office visits, glasses and contacts, and dental work add up over the course of a year. With an FSA, you can save 30% on these expenses by paying for them with pre-tax dollars.

Keep your money. It can be a challenge to estimate how much money to set aside each year in an FSA. But now you have a $500 safety net! Government regulations allow you to carryover up to $500 (if allowed by your employer) of your unused Health FSA funds from year to year.

How much will you elect this year? Enrolling in an FSA is a savvy way to save money on health expenses. Everyone who anticipates any out-of-pocket medical expenses should take advantage of the benefits of an FSA. There is no risk to contribute at least $500. At the end of the year, if your medical expenses are below that amount, you can carryover any amount up to $500 and use it next year—with no cost or penalties.

If you’ve participated in an FSA in the past, you already know how much you can save. And now you’re safe to increase your annual election, knowing if you don’t use it this year, you can carryover a maximum of $500 to the next year with no risk of forfeiture at the Plan Year end.

FSA contributions are deducted pre-tax from your payroll. The more you elect, the more your taxable income is reduced—which means more take-home pay! Be money smart. Enroll in a medical FSA today!

Carryover for Healthcare FSA

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Be Money Smart

Contribute up to $500 in a Health FSA with no risk of losing it at year's end.

Total Administrative Services Corporation2302 International Lane I Madison, WI 53704-3140

Available for these FlexSystem Plans• Healthcare FSA• Dependent Care FSA

Get Started Today!Download the MyTASC Mobile App on your mobile device today for easy, secure, and convenient account access. It’s free and available on the following platforms:Apple® App Store I Android Google Play™ I Amazon AppStore

Activate MyTASC Text Messaging and/or email notifications online by logging in to your MyTASC account online and selecting “Set Notifications.”

TASC Mobile provides quick and easy access to your FlexSystem account(s)—from anywhere at any time.

Securely check real-time balances, request a reimbursement, view transaction details, and review plan information...all from your mobile device.

MyTASC Mobile AppDownload the app for free to your smartphone or tablet. Securely log in using your current MyTASC username and password to conveniently perform the following functions:

• Submit a request for reimbursement for out-of-pocket FSA expenses. Upload pictures of receipts with phone camera.

• View real-time account balances and transactions for active and closing plans, and your MyCash account.

• Review FlexSystem Plan information and annual contributions.

• Enable login memory for faster return access (per device).

MyTASC Text Messaging (SMS)Text messaging is available for convenient access to your FlexSystem account(s) from your mobile phone through instant two-way communication.

• Request your current account balance

• Request a reimbursement

• Receive automated reimbursement status alerts

Mobile Tools

Easily access your FSA while on the go!

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Total Administrative Services Corporation2302 International Lane I Madison, WI 53704-3140

Get more information about TASC Mobile at:www.tasconline.com/mobile

• Limited Purpose FSA

BENEFITS ENROLLMENT FORM Please print this form, sign, and return to your employer for processing.

EMPLOYEE INFORMATION

Employee Name: Last Name First Name Middle Initial

Social Security Number: Date of Birth: Gender:

Home Address: Street City State Zip Code

Email Address: Telephone #:

EMPLOYER/BENEFITS INFORMATION Employer Name: Date of Hire: Plan Effective Date: Date of 1st Payroll Deduction: Insurance Carrier Name:

PLAN ELECTIONS

Plan Type Annual Election ($)

Number of Payrolls

Amount per Pay Check ($)

Employer Contribution (if applicable)

Per Month Per Year Healthcare Flexible Spending Account (FSA): Dependent Care FSA: Limited Plan FSA (Dental and Vision Only): Health Reimbursement Arrangement (HRA): Health Savings Account (HSA):

Transportation Benefit Account:

Parking Benefit Account:

FOR DEPENDENT COVERAGE: Married? Yes No Dependent Children? Yes No

If Yes, list your spouse and dependent children below:

Last Name First Name Social Security Number*

Relationship to Employee Date of Birth* Gender

AUTHORIZATION I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming expenses either reside with me in a parent-child relationship or are legally dependent on me for their support. I understand that any amounts remaining in my account(s) not used for qualified expenses incurred during the Plan Year will be forfeited in accordance with current Plan provisions and tax laws. Furthermore, I agree that the IRS regulations state four conditions: (1) any expenses I/we incur must be within the Plan Year; (2) any expenses I/we incur must not be covered by any other sources, such as insurance; (3) I/we must provide proper documentation to receive payment; (4) I/we cannot change or revoke elections during the Plan Year unless there is a specific change in status and my employer allows such changes. Please see Summary Plan Description for details. Employee Signature Date

* Social Security and date of birth for employees and their dependents are required for HRA reporting purposes to the Centers for Medicare and Medicaid Services as part of the Medicare, Medicaid, and SCHIP Extension Act of 2007. Enrollment Forms without this required information will be returned for completion.

Total Administrative Services Corporation (TASC) | P.O. Box 7511 | Madison, WI 53707-7511 Phone: 877-933-3539 | Fax: 877-231-1287

TC-5544-022016

Additional Debit Card Request

I authorize the “Additional Card Holder” listed above to receive a TASC debit card tied to my TASC account

Please fax or mail completed forms to: Total Administrative Services Corp (TASC) | PO Box 7511 | Madison, WI 53704-7511 | Phone: 1.877.933.3539

Toll Free Fax: 1.877.231.1287 I TC-5517-121515

PARTICIPANT INFORMATION

Participant Name

Employer Name

Employee ID

Address Apt #

City State ZIP

ADDITIONAL CARD HOLDER INFORMATION

First Name Middle Initial

Last Name

Date of Birth (mm/dd/yyyy)

Signature Date

Direct Deposit Authorization

IMPORTANT: Please provide a voided check for the account listed above. We will not process without a voided check. Do not use a deposit slip as the number may be invalid. Authorization I authorize reimbursements from my TASC Health FSA, Dependent Care, Transit, or HRA benefits to be sent to the financial institution named above to be deposited in the designated account. In the event funds are deposited erroneously into my account, I authorize TASC to debit my account(s) not to exceed the original amount of the credit. I also understand that all direct deposits are made through the automated clearing house (ACH) and that fund availability is subject to the terms and limitations of the ACH as well as my financial institution.

Please fax or mail completed forms with a voided check to: Total Administrative Services Corp (TASC) | PO Box 7511 | Madison, WI 53707-7511 | Phone: 877-933-3539

Fax: 877-231-1287 I TC-5522-121515

PARTICIPANT INFORMATION

Participant Name

Employer Name

Employee ID

Address Apt #

City State ZIP

Email Address

BANK ACCOUNT INFORMATION

Bank Name Checking Account Savings Account

Bank Address

City State ZIP

Name on Account

Account Number Routing Number

Signature Date