Flexible Spending Account Election

For Employees with a Qualifying Life Event Only

PLEASE NOTE:

PLEASE NOTE: To enroll in a flexible spending account using this form, please complete, sign electronically or manually, and return
to the Employee and Retiree Service Center (ERSC). You may fax the signed form to 301-279-3651 or 301-279-3642, or email a PDF of
the signed form to ERSC@mcpsmd.org. Please only submit your elections via one method. Submitting via multiple methods can cause errors
and delay the processing of your elections. Please visit the ERSC website for additional information. A confirmation of your elections will be sent
to you.

Flexible Spending Account Election For Employees with a Qualifying Life Event Only

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