ECTION 125 - FLEXIBLE BENEFIT PLAN

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					SECTION 125 - FLEXIBLE BENEFIT PLAN

        ENROLLMENT GUIDE
    FOR THE EMPLOYEES OF THE
      CITY OF FORT WORTH

        FOR THE PLAN YEAR
JANUARY 1, 2011 – DECEMBER 31, 2011
                                                                                                                    2

Dear City of Fort Worth Employee,

Ben Franklin once said, “Nothing is certain but death and taxes.” And he was right. Paying taxes may be inevitable, but
that doesn’t mean that we have to pay more than our fair share. Congress has designed a few ways for us to save on
taxes – not loopholes, but programs that Congress purposely created to benefit taxpayers at all income levels. One
such program is the CITY OF FORT WORTH FLEXIBLE BENEFIT PLAN. By signing up for the FLEXIBLE BENEFIT
PLAN, you will INCREASE YOUR TAKE HOME PAY. This means that the withholding taxes currently being deducted
from your check will decrease when you enroll in the FLEXIBLE BENEFIT PROGRAM.

                                     WHAT IS THE FLEXIBLE BENEFIT PLAN?

The Flexible Benefit Plan offered by the City of Fort Worth allows you to reduce your taxable income and increase
your take-home pay by permitting you to select various employee benefits to be paid on a non-taxable basis. If you
elected coverage under the medical and/or dental insurance plan the City of Fort Worth deducts those insurance
premiums from your check before taxes are computed. By paying your premiums before your income is taxed, you
never pay federal income tax (FIT) or FICA tax on those dollars. Because the cost of insurance is deducted before
taxes are computed, you pay taxes on a lesser amount of money. Therefore, you pay less in taxes. The tax savings is
at least 16.45% (15% FIT + 1.45% FICA) in most cases.

                          WHAT OTHER EXPENSES CAN I PAY ON A PRE-TAX BASIS?

Besides insurance premiums, the Flexible Benefit Plan allows you to further INCREASE YOUR TAKE HOME PAY by
setting up accounts that permit you to pay your out-of-pocket medical, dental, vision, dependent day care and adoption
assistance expenses before taxes are calculated. Examples of some out-of-pocket expenses may be:

Deductibles                                           Co-Insurance
Co-Pays                                               Prescription Drug Co-Pays
Dental/Orthodontia Expenses                           Vision Expenses/Lasik Surgery
Infertility Treatments                                Chiropractic Care
Over the Counter Expenses – LIMITED IN 2011!!

To pay the above out-of-pocket expenses on a pre-tax basis, a Health Care (medical/dental/vision) Spending Account,
administered by Taxsaver Plan can be elected. The maximum contribution for the Health Care Spending Account is
$4,200.00 per plan year. Please refer to the “Deductible Medical Expenses” page enclosed in this packet for detailed
information on eligible medical/dental/vision expenses, or refer to www.taxsaverplan.com .

In addition to the Health Care Spending Account, there is a Dependent Care Spending Account that allows you to
reimburse yourself with pre-tax dollars for out-of-pocket expenses, such as:

Preschool Tuition                                     Before & After School Care
Summer Day Camps/Activity Camps                       Care for Disabled Dependents

The maximum contribution for the Dependent Care Spending Account is $5,000 for the calendar year. If your spouse
does not work, is not a full time student, or is not disabled, you are not eligible to participate in the Dependent
Care Account.

Lastly, there is an Adoption Assistance Account that allows you to reimburse yourself with pre-tax dollars for out-of-
pocket qualified adoption expenses such as:

       Adoption Fees
       Attorney Fees
       Court Costs associated with adoption proceedings

As you know, the higher your taxable income, the more you pay in taxes. If you recognize out-of-pocket expenses that
you and your family continually incur, you will benefit from a Health Care Spending Account and/or a Dependent Care
Spending Account. If you can reduce your taxable income by electing a Spending Account, the end result will be less
taxable income and fewer dollars that you will pay in taxes.




Administered by Taxsaver Plan www.taxsaverplan.com
                                                                                                                           3
                                          How Do Spending Accounts Work?

For the Health Care Spending Account, first estimate how much money you and your family (those who you can claim
on your tax return as dependents) anticipate spending on eligible medical/dental/vision expenses not paid by insurance
during the plan year (01/01/11 – 12/31/11). Any health care expenses incurred prior to the first day of the plan year
(01/01/11) or prior to the first day of your enrollment are not eligible for reimbursement. You do NOT have to elect
coverage for yourself, or for your dependents, under the insurance plan(s) offered by City of Fort Worth in order to
participate in the Health Care Spending Account. Once you have identified your out-of-pocket expenses and
determined the cost of those services incurred during the plan year, divide the approximated amount by the number of
actual paychecks received (26) during the plan year. That determined amount will be deducted from your pay check
each pay period BEFORE your income is taxed. Therefore, you will pay federal withholding and FICA taxes on a lesser
amount of income each paycheck.

For the Dependent Care Spending Account, first estimate your dependent care expenses for the plan year (01/01/11 –
12/31/11). Any dependent care expenses incurred prior to the first day of the plan year (01/01/11), or prior to the first
day of your enrollment are not eligible for reimbursement. Once you have identified your dependent care expenses and
determined the cost of those services incurred during the plan year, divide the approximated amount by the number of
actual paychecks received (26) during the plan year. That determined amount will be deducted from your pay check
each pay period BEFORE your income is taxed. Therefore, you will pay federal withholding and FICA taxes on a lesser
amount of income each paycheck.

For the Adoption Assistance Account, estimate the amount of expenses that you have spent in the prior year for
eligible adoption expenses. You may also include any eligible expenses that you will incur this year if this year is the
year that the adoption becomes final. For foreign adoptions, expenses are only allowed in the year that the adoption
becomes final.

The amount that you elect to be taken from your pay on a pre-tax basis will be redirected into the account(s) designated
on your enrollment form.

During the plan year, you may file claims for reimbursement of any eligible expenses as you, or your family member,
incur the expense. After the plan year has ended, you have until March 31, 2012 to file claims for expenses incurred
during the plan year. You pay no taxes on these reimbursements or the dollars that have been deducted pre-tax and
redirected to the Spending Account(s) that you elected.

                                   Are There Any Concerns I Should Know About?

Yes, once you enroll in the Flexible Benefit Plan, your elections will remain in effect for the entire plan year and cannot
be changed unless you experience a qualifying status change.

Each plan year functions independently from the last, so that you may make a change of election for the upcoming plan
year during the open enrollment period offered by your employer. You may change your election during the existing
plan year if you have a qualified status change. The election change must be on account of and consistent with a
qualified status change and, the qualified status change must result in a gain or loss of eligibility to coverage
in order for an election change to occur. Qualified status changes, as defined by the IRS are:

                   Change in Employee’s Legal Marital Status, including marriage, divorce, death of a spouse, legal
                    separation or annulment.
                   Changes in the number of tax dependents, including a birth, adoption, placement for adoption or
                    death.
                   Employment Status including a termination or commencement of employment, a strike or lockout, a
                    commencement of or a return from an unpaid leave of absence or a change in worksite.
                   Dependent Satisfies (or Ceases to Satisfy) dependent eligibility (as determined by the IRS) due to
                    attainment of limiting age, gain or loss of student status, marriage or any other similar
                    circumstance.
                   Changes in Residence of employee, spouse or dependent.

Election changes may also be permitted due to change in cost/coverage of health plan coverage, Medicare/Medicaid
entitlement, HIPAA and the like.
Any changes in elections must be made within 30 days of the qualifying status changes listed above except birth,
adoption, and placement for adoption must be made within 60 days. All changes should be submitted to your employer,
where they will be reviewed for eligibility.



Administered by Taxsaver Plan www.taxsaverplan.com
                                                                                                                                       4

                                                 IMPORTANT INFORMATION

These accounts operate on a “USE IT OR LOSE IT” basis. You should plan carefully when electing your
Spending Account contribution. Once you sign up for the plan, the dollars that are deducted pre-tax will remain
in the designated account(s) until you file eligible claims for reimbursement. Funds cannot transfer between
the three Spending Accounts. You may not access the funds in the account without filing an eligible claim, as
deemed eligible by the Plan. Any unused dollars remaining in the account at the end of the open claims period
will be forfeited to your employer. Federal Law requires that you lose those dollars.

                                             How Much Can I Save On Taxes?

Your actual tax savings depends on a number of factors, including your tax bracket and how much you contribute on a
pre-tax basis to the Flexible Benefit Plan. For your personal exact tax savings, please refer to our website
www.taxsaverplan.com and click on the “Benefits Calculator”.


                                          How Do I Use My Spending Account?

Incur an eligible expense. For this plan, it is the date of service, not the date of payment that determines whether or
not an expense is eligible for reimbursement. The date of service must fall within this plan year (01/01/11 – 12/31/11). If
you become eligible during the plan year, the date of service must fall between the date that you sign up for the plan
and the end of the plan year. If you should terminate during the plan year, expenses incurred after your date of
termination are not reimbursable, unless you elect COBRA for the Health Care Spending Account and make the
required after-tax payments to the account.

Once you have incurred an eligible Health Care expense, fill out a claim form (available at www.taxsaverplan.com).
Attach copies of the receipts from the health care provider and submit the claim to Taxsaver Plan. Please be sure that
the copy of the receipt states the date of service and type of service for all services rendered. If you are submitting
prescription drug receipts, please also make sure the name of the drug is on the receipt. If the expense is reimbursable
by your Insurance Provider, please submit the claim to them first. After the Insurance Provider sends you an EOB
(Explanation of Benefits), please submit a copy of the EOB to Taxsaver Plan, so they may reimburse you any
deductible costs or co-insurance costs. If the expense is not covered by insurance, please submit a copy of the itemized
receipt directly to Taxsaver Plan. All expenses must be for the treatment or mitigation of a specific medical condition or
disease. General Health and/or cosmetic items or procedures are not eligible for reimbursement under this plan.

You may elect to receive the FSA Debit Card to pay for your out of pocket medical, dental, vision, prescription and
eligible over-the-counter expenses. You must complete the section of the Enrollment Form pertaining to Debit Cards to
receive the card. If you plan to elect the FSA Debit Card, please read on.

Health Care FSA Debit Card                                     Receipt Requests for FSA Debit Cards
Once you become eligible to participate and elect the FSA      You may receive a receipt request for additional follow-up
Debit Card you will receive two cards in the mail to be used   documentation for the following reasons:
for Health Care FSA expenses.
You are not required to activate the card. Each card has       Your provider is charging the wrong co-pay amount to the card
the participant’s name on the card but a different card        (hint: the card will still work at the time the service is provided).
number.
If the amount charged to the FSA Debit Card matches a          You have used the card to pay for a deductible or co-insurance
co-pay (or co-pay multiple) under your Employer’s health       expense (hint: the card will still work at the time the service is
plan, you will not be asked to submit a receipt.               provided). This often occurs at a hospital.
As long as you use the card at a participating pharmacy        You have a recurring expense, such as a monthly fee from the
(see list on Taxsaver Plan’s website) you will not be asked    Orthodontist, and this is the first time you have used the FSA
to submit documentation for prescription or over-the-          Debit Card. Once you submit the documentation & it is approved,
counter items!                                                 future dollar amounts equal to the initial charge will pass through
                                                               without a request for additional documentation. This is called a
                                                               recurring expense.
Your card may be denied when you are out of funds or           Finally, request for additional receipt documentation does not
when you are at a non-participating provider – not sure?       mean that your provider has not been paid. It only means that the
Call Taxsaver Plan’s CSR!                                      amount charged to the card is not meeting the required tests to
                                                               pass through without being flagged. By sending in your itemized
                                                               provider statements within 35 days from receipt of the notice,
                                                               your card stays active!




Administered by Taxsaver Plan www.taxsaverplan.com
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If you are asked to submit a paper receipt for a Debit Card expense, attach copies of the itemized statement from the
health care provider and submit the notice that you will receive by email to Taxsaver Plan. Please be sure that the copy
of the itemized statement provides the date of service and type of service for all services rendered. If you are submitting
prescription drug receipts or over the counter item receipts, please also make sure the name of the drug or over the
counter item purchased is on the receipt. All expenses must be for the treatment or mitigation of a specific medical
condition or disease. General Health and/or cosmetic items or procedures are not eligible for reimbursement under this
plan. In order to receive a debit card, you must provide a working email address to the City (please refer to the
enrollment form).

Once you have incurred an eligible Dependent Day Care expense, fill out a claim form and attach the receipt from your
care provider. Make sure that the receipt states the dates of care, the cost for the care and the signature of the care
provider. Remember that you may only participate in the Dependent Care Spending Account if you and your spouse are
employed, if your spouse is disabled, or if your spouse is a full time student. Taxsaver Plan does not need the tax
identification number of your provider or day care center. However, you will need the tax identification number of your
provider when you file your taxes at the end of the tax year.

Reimbursement checks will be mailed to your homes each Monday. If you complete the attached direct deposit
form found on page 11, you will receive your funds directly into your bank account of choice, on Monday. In
order to ensure timely reimbursement, please submit your claims to Taxsaver Plan by Tuesday at 3:00 PM CST and
please keep your address current with your employer. You are responsible for the health care expenses that you
submit. Please do not submit expenses that are not eligible for reimbursement. If you are unsure if an expense is
reimbursable, please contact Taxsaver Plan. You are also responsible for any IRS penalties resulting from
reimbursement of an ineligible expense.

                                       How Do I Enroll For Direct Deposit?

If you wish to have your FSA funds, either Health Care Spending Account or Dependent Care Spending Account funds,
directly deposited into your bank account of choice, please complete the Direct Deposit Enrollment Form found on page
11 and submit the form and a voided check directly to Taxsaver Plan at any time. Please allow Taxsaver Plan 5
business days to process the form.

When you submit a claim, Taxsaver Plan will process the reimbursement on Friday, as usual, and you will receive an
email – if Taxsaver Plan has your email address – notifying you that the funds will be available in 48 business hours. If
Taxsaver Plan does not have an email address on file, you will receive a notification in the mail alerting you that the
funds have been deposited. Any changes to your banking information must be submitted to Taxsaver Plan. The forms
for Direct Deposit enrollment are always available on your Account Balance page on their website.

                        How Do I Enroll in the Flexible Spending Account Program?

Complete the enrollment form accompanying this material on Pages 9 and 10. It must be received in the Human
Resources Department (Lower Level City Hall) no later than 5pm on _____October 29, 2010_________-- for this
Open Enrollment period or, within 30 days of your hire date for new employees. After that date, you may
change your election only for a qualified Change in Status (see page 3).

If you have any questions after reading this material, please contact Taxsaver Plan at (800) 328-4337. For additional
information, please view Taxsaver Plan’s website at www.taxsaverplan.com.




Administered by Taxsaver Plan www.taxsaverplan.com
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                     Reimbursable Expenses Under the Health FSA Plan


      Air Conditioner to Treat Illness*                   Obstetrician
      Acupuncture Treatments*                             Oculist
      Ambulance Fees                                      Operations (cosmetic operations
      Anesthesiology                                       excluded)
      Artificial Limbs                                    Ophthalmologists
      Automobile Modifications                            Optometrist
      Birth Control (Rx and non-Rx)                       Oral Surgery
      Blood Donor Expenses                                Orthodontia (children and adults)
      Braille Books/Magazines                             Osteopath
      Chiropractor                                        Over the Counter Drugs & Items**
      Christian Science Practitioners                     Oxygen Equipment
      Clinic Fees                                         Pediatricians
      Contact Lenses & Solutions                          Physicians
      Co-payments                                         Physiotherapists
      Deductibles                                         Physical Therapy
      Dental Exams & Procedures (cosmetic                 Psychiatrist
       procedures excluded)                                Psychologist
       Diagnostic Tests                                    Reconstructive Surgery (must be
      Diathermy                                            medically necessary)
      Drugs (prescription)                                Rental of Medical Equipment
      Drug Treatment Programs                             Retirement Home Medical Fees
      Eye Exams                                           Seeing Eye Dog Costs
      Eye Glasses (reading glasses included)              Sex Therapist
      Fertility Treatments                                Smoking Cessation Programs
      Gynecologists                                       Syringes (diabetic supplies)
      Hearing Devices & Batteries                         Support or Corrective Devices
      Insulin                                             Surgeons
      Lasik Eye Surgery                                   Vasectomy
      Mammograms                                          Weight Loss Programs*
      Massage Therapy*                                    X-rays
      Mental Health Treatments (inpatient &
       outpatient)
      Midwife
      Nurse (practical)



          Cosmetic prescriptions and procedures or supplies are not eligible for reimbursement
          All expenses must be for the treatment or mitigation of a specific medical condition or
           disease
          NEW FOR 2011: ** indicates that many items will require a written prescription by a
           physician or other licensed practitioner authorized to prescribe drugs in your state
          A letter may be requested from your physician to substantiate the medical necessity of
           an expense (especially where you see a *). Physician Medical Determination Forms are
           available on our website under Forms
          For additional information on eligible over the counter expenses and the other expenses
           you see listed, go to www.taxsaverplan.com, Eligible Health FSA Expenses
          This list does not intend to be all-encompassing, but should be used as a general
           guideline to determine eligible expenses




Administered by Taxsaver Plan www.taxsaverplan.com
                                                                                                      7
                                  OVER-THE-COUNTER ITEMS IN 2011
ALERT!
READ THIS PAGE….


    Due to the Patient Protection and Affordable Care Act and the Health Care Reconciliation Act of
    2010, items once considered eligible for reimbursement under a Health Flexible Spending
    Account will now require a prescription from a licensed practitioner authorized to prescribe drugs
    in your state.

    This becomes effective January 1, 2011…only for items purchased on and after January 1, 2011.
    Items purchased in 2010 but not yet submitted for 2010 reimbursement will not be affected by the
    new regulations.

    It is necessary to submit your physician’s prescription with each request for reimbursement for
    certain over-the-counter items.

    As of 01/01/2011, your FSA Debit Card, should you have one, will no longer be accepted to pay
    for certain over-the-counter expenses that were once considered to be eligible.

    EXAMPLES OF ELIGIBLE EXPENSES AVAILABLE FOR PURCHASE WITH THE DEBIT CARD
    OR FOR REIMBURSEMENT WITHOUT A PHYSICIAN’S PRESCRIPTION:

          Band Aids
          Birth Control
          Braces & Supports
          Catheters
          Contact Lens Supplies & Solutions
          Denture Adhesives
          Diagnostic Tests & Monitors
          Elastic Bandages & Wraps
          First Aid Supplies
          Insulin & Diabetic Supplies
          Ostomy Products
          Reading Glasses
          Wheelchairs, Walkers, Canes and other Durable Medical Equipment

    EXAMPLES OF INELIGIBLE EXPENSES NO LONGER AVAILABLE FOR PURCHASE WITH
    THE DEBIT CARD THAT WILL REQUIRE A PHYSICIAN’S PRESCRIPTION IN ORDER TO
    RECEIVE A REIMBURSEMENT:

                   Acid Controllers                           Digestive aids
                   Allergy & Sinus meds                       Feminine Anti-Fungal/Anti-
                   Antibiotic products                         Itch products
                   Anti-Diarrheals                            Hemorrhoidal pads
                   Anti-Gas meds                              Laxatives
                   Anti-Itch/Insect bites meds                Motion sickness meds
                   Baby rash                                  Pain relievers
                    ointments/creams                           Respiratory treatments
                   Cold sore remedies                         Sleep aids/sedatives
                   Cough, cold & flu meds                     Stomach remedies


    Administered by Taxsaver Plan www.taxsaverplan.com
                                                                                                                          8
Worksheet to Determine Your Eligible Out of Pocket Expenses

Type of Expense                  Number of            Multiplied    Amount of             Total For 12 Month
                                 Times Incurred       By            Expense               Period
                                 in 12 Months
HEALTH FSA:
 Office Visits                                        X
 Prescriptions                                        X
 Annual Well Woman                                    X
 Annual Mammogram                                     X
 Chiropractic Care                                    X
 Therapist Visits                                     X
 Routine Lab Work                                     X
 Maternity Care                                       X
 Infertility Treatments                               X
 Dermatologist Visits                                 X
 Eligible Over-the-Counter                            X
 Items
 Speech Therapy Visits
 Physical Therapy Visits
 Out of Network Provider Fees
 Dental Exams                                         X
 Cavities & Sealants                                  X
 Crowns/Dentures
 Orthodontia Fees                                     X
 Eye Exams                                            X
 Contact Lenses                                       X
 Frames & Lenses                                      X
 Lasik Procedures
 Total Health FSA:


Day Care Costs for Children
ages 0-5 (or eligibility for                          X
kindergarten):
 Baby Sitter/Nanny Fees                               X
 Before & After School Care                           X
 Activity Programs/Camps
 Summer Day Camps                                     X
 Total Day Care:                                      X

 Adoption Assistance
 Expenses:
 Court fees
 Adoption fees
 Attorney fees
 Total Adoption Assistance:
 Additional Expenses Not
 Listed:
                                                      X

Grand Total:

 You cannot claim both a tax credit under Section 23 and a tax exclusion under Section 137 if the IRS Code
  for the same adoption expenses.
 Different additional expenses that exceed the maximum under Section 23 may be claimed under Section 137
 Refer to IRS Publication 968 for additional information. This publication is available online at www.irs.ustreas.gov.
  A copy is available for your inspection in the Human Resources Department (Lower Level City Hall).




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                                                                                                                                            9


                                    SECTION 125 ENROLLMENT FORM
                              CITY OF FORT WORTH FLEXIBLE BENEFIT PLAN

This agreement is made as of ____________________________, 2011 between CITY OF FORT WORTH, Employer, and

_____________________________________________________________________, Employee. (Please Print Name)
Whereas, Employee wishes to obtain the benefits of Internal Revenue Code Sections 125, 129 and other sections, as amended, that provides
benefits. And, whereas, Employer is willing to assist Employee in obtaining said benefits. Therefore, it is mutually agreed as follows:



 Health Care Flexible Spending Account:
 I wish to contribute to the Unreimbursed Medical/Dental/Vision Account for the Plan year for eligible expenses that I may incur during
 this Plan Year, during my period of eligibility under the Plan.

 [   ] I wish to contribute $_________ per pay period for a yearly total of $_________ (NOT TO EXCEED $4200)

 Debit Cards for Health Care Spending Account:
        1) I certify that upon enrollment and each plan year thereafter, I understand this card is to be used only for eligible medical
            care expenses as defined in Section 213 (d), of the employee, the employee’s spouse and dependents. I also certify that
            any expense paid with the card has not been reimbursed and that I will not seek reimbursement under any other plan
            covering health benefits.
        2) This card is not to be used for personal items, other than eligible expenses as defined by the Plan. If the card is used for
            ineligible expenses, you will be required to reimburse the Plan for ineligible expenses paid for by the card. Use of the card
            for ineligible expenses is fraudulent and may result in disciplinary action, to be determined by your Employer.
        3) I also understand that each time I use my card, I reaffirm the statement above.
        4) If I do not substantiate FSA Debit Card transactions by the end of the Plan Year run-out period (when receipts are
            requested by Taxsaver Plan), I understand that my Employer will issue a 1099 for all ineligible/unsubstantiated amounts
            or include the ineligible/unsubstantiated amounts as income on my W-2 the following year. All ineligible/unsubstantiated
            amounts are required to be reported to the Internal Revenue Service.

 You will be asked to submit receipts for purchases made with the FSA debit card. You will receive emails from claims-
 ftw@taxsaverplan.com requesting the receipts that are needed. Please do not ignore these requests and do not throw away
 your receipts. Your card is ready for use once it is received. You must have an email address to utilize the FSA Debit Card.
 Please provide us with an email address below:

 EMPLOYEE ID:    _________________________________
 EMAIL ADDRESS YOU WISH TO USE FOR THE FSA PLAN:




 I acknowledge that electronic messages sent or received using the City of Fort Worth’s electronic communications systems are
 generally considered public and may be subject to review and public disclosure as set forth in the Electronic Communications Use
 Policy, Administrative Regulations D-7. You may change your email address online with Taxsaver Plan at any time during the year.
 HOME ADDRESS:




 Street Address Above:



 City, State and ZipAbove

 CITY OF FORT WORTH HEALTH PLAN SELECTION (Please check one):
 [ ] BASIC         [ ] BASIC PLUS           [ ] WAIVED COVERAGE




       Administered by Taxsaver Plan www.taxsaverplan.com
                                                                                                                                      10
 Dependent Care Flexible Spending Account:
 I wish to contribute to the Dependent Care Account for the Plan year for eligible expenses that I may incur during this Plan Year,
 during my period of eligibility under the Plan.

 [   ] I wish to contribute $_________ per pay period for a yearly total of $_________ (NOT TO EXCEED $5000 per family)



                                          SECTION 125 ENROLLMENT FORM
                                             FOR CITY OF FORT WORTH

I hereby authorize the necessary salary reduction from my pay to make the contributions indicated above. I
understand that these choices cannot be changed during the Plan Year, unless I have a status change as
defined by the IRS. I further understand that if I fail to use all of my Flexible Spending Account contributions to
reimburse myself for eligible expenses incurred during the Plan year, I will forfeit any remaining amount(s), as
provided by IRS Code Section 125. Any pre-tax deductions that are not taken on my scheduled pay date will
be deducted on future pay checks on a pre-tax basis during the Plan Year. The City Of Fort Worth may choose
to recalculate the per pay period amount to ensure that the annual election amount will be met by year end.

If Employee’s employment is terminated, this agreement will terminate. However, Employee retains the right to
convert or continue any of the Plans as provided by The Plan. Further, the Employee may not revise this
agreement except as stated by The Plan in the Plan Document.



____________________________________________                                     _________________________
Employee Signature                                                                      Employee ID Number



_________________________________                                                     _________________________
Employee Social Security                                                                         Date




       Administered by Taxsaver Plan www.taxsaverplan.com
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                      Election Form for Direct Deposit of Funds
                      From the Flexible Spending Account Plan
                                                    At
                                    The City of Fort Worth

I authorize Taxsaver Plan, on behalf of the City of Fort Worth, to Direct Deposit my Dependent
Care and/or Health Care Spending Account Reimbursements. I understand that it is my
responsibility to inform Taxsaver Plan if I should change my bank account. I understand the funds
will be deposited into the account listed below. Only one account may be listed.

**YOU MUST ALSO SEND A VOIDED CHECK WITH THIS FORM TO CONFIRM THE
INFORMATION IS CORRECT**



(Checking or Savings account number)
[ ] Check this box if this is a checking account.
[ ] Check this box if this is a savings account.




(Routing number 9 digits)

____________________________________                        ___________________
(Signature)                                                 (Social Security)

____________________________________                        ___________________
(Please print name)                                         (Date)

EMAIL ADDRESS:




 Please fax this form to 214-528-8122 or mail to PO Box 609002 Dallas TX 75360. Please
 allow one week for processing.




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                                                                     12

                             This Page Is Intentionally Left Blank




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Flexible Spending Account Claim Form
City of Fort Worth
__________________________________________________________________________________________
Name of Employer (please print)                           Social Security Number (or last 4 digits)

__________________________________________________________________________________________
Employee Last Name (please print)          First Name

                                   Dependent Day Care Expenses for Reimbursement

 $___________Service Dates of Day Care from __ / ___ 20___ to __ / __ 20___

 Dependent(s) Name(s) _________________ , ___________________ , ___________________, _____________
 Dependent(s) Age(s) ____________________ (required for Dependent Day Care Reimbursement)

                            Please provide receipt OR complete the following information:
 I certify that I have provided the custodial care for the dependent(s) named above for the service dates mentioned
 above.
 ____________ _____________________________________________________
 Date Day Care Provider Signature **Please note the employee must still complete the Participant Certification portion of this
 form


                                  Health Care Expenses for Reimbursement
 Health Care Expenses (Request for reimbursement of non-benefitcard expense(s))                        $___________

                                           OR CHECK ONE OF THE FOLLOWING:

 [          ] This is a FSA Benefit Card Expense (not a personal bank account debit card transaction)

 [         ] This expense should be used to offset my outstanding FSA Benefit Card transaction(s), in the amount of

 $___________ as I am unable to produce the receipt(s) or I have used the card for an ineligible item(s).


                                                            Participant Certification
                                      (this section must be signed and dated for reimbursement requests)
 I testify that I have attached records necessary to substantiate these expenses. I understand that since these expenses are
 reimbursed through my spending account that they may not be claimed on any federal income tax deduction or credit at year end.
 I further certify that I will not submit these expenses for payment by a third party, such as my major medical plan, or any other
 health plan, such as an individual policy or my spouse’s or
 dependents health plan. If this expense was paid for with my Flex Debit Card, I understand that the card is not to be used for
 personal items, other than eligible expenses under the Plan. Should I use the card for ineligible expenses, I am required to
 reimburse the Plan for the ineligible expenses paid for by the card. I attest that any over the counter expenses have been incurred
 for the primary purpose of the alleviation or prevention of a physical or mental defect or illness and is not for cosmetic purposes
 and will be used by myself, spouse and/or dependents. All expenses submitted for request of reimbursement or claim
 substantiation are for myself and / or qualified spouse and / or qualified dependent(s) under federal guidelines.

 _________________                _________________________________________________________________
 Date                             Employee Signature
 Documentation Required:
 Dependent Care Expenses: You must submit itemized receipts that substantiate the date of care, amounts paid for the care and
 the name of the provider OR have your day care provider sign the Dependent Day Care Reimbursement portion of the claim form
 certifying that services have been rendered.
 Health Care Expenses: You must submit Health Plan receipts (Explanation of Benefits) sent from your health plan provider that
 substantiate deductibles, copays, coinsurance or other expenses not covered by a health plan, itemized receipts from health care
 providers that substantiate the date of service, type of service, cost of service and the name and phone number of the provider or
 itemized receipts for eligible over the counter expenses with the name of the drug or item and the date of the purchase printed on
 the receipt from an independent third party. Please note balance forward statements, canceled checks and credit card receipts are
 not acceptable.
 Over The Counter Medicines and Drugs: For OTC medicines and drugs incurred on or after 1/1/2011, you must submit the
 itemized receipt for the expense along with a written prescription from a person legally authorized to prescribe medications in the
 state in which the expense was incurred, or submit the itemized receipt containing the state issued RX number if the OTC
 medication or drug was dispensed by the pharmacist as a prescription.


Administered by Taxsaver Plan www.taxsaverplan.com
                                                                                                    14

Remember To:

   1) Sign and date your SECTION 125 ENROLLMENT FORM and verify your Social Security Number and
      Employee Number.

   2) Remove Pages 9, 10,11,12 and 13 and return the enrollment form (page 9 and 10) to:

      City Of Fort Worth
      Human Resources Department
      Benefits Office
      1000 Throckmorton
      Fort Worth, Texas 76102
      (Lower Level City Hall)

   AS SOON AS POSSIBLE, BUT NO LATER THAN 5:00 PM ON:
               OPEN ENROLLMENT Friday, October 29, 2010
               NEW EMPLOYEES – within 30 days of your hire date.

   3) Keep this booklet and completed worksheets for your files

   4) File your initial claim form for reimbursement using the Claim Form on Page 13. Another claim form
      will be mailed to you with your reimbursement check. Claim forms are also available in the Human
      Resources Benefits Office and online 24 hours a day at www.taxsaverplan.com.

   5) Your reimbursement check or direct deposit advisement will be mailed to the address on file with
      the City of Fort Worth’s Human Resources Department. Be sure to keep your address updated with
      the City at all times.

   6) Questions? contact…

      City Of Fort Worth’s Benefits Office at (817) 392-7782
      Or
      Taxsaver Plan at (800) 328-4337
      You may also log onto their website at www.taxsaverplan.com




Administered by Taxsaver Plan www.taxsaverplan.com

				
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