FormsStaffBenefits → Flexible Spending Account Calendar Year 2022 Election

Flexible Spending Account Calendar Year 2022 Election

For Employees with a Qualifying Life Event Only

About this Form

Form number: 450-3

Audience:  MCPS Staff

Last revised: November 2021

Related Forms

Form 450-1 - Optional Employee Term Life Insurance

Form 450-2 - Optional Dependent Term Life Insurance

Form 455-20 - Employee Benefit Plan Enrollment

PLEASE NOTE: To enroll in a flexible spending account for 2022, please complete the Flexible Spending Account Calendar Year 2022 Election form at the link below, 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.

 

If you wish to change your 2021 FSA election, you must use the Flexible Spending Account Calendar Year 2021 Election form. Please be sure to use the form for the calendar year in which you are enrolling.

Adobe PDF Flexible Spending Account Calendar Year 2022 Election
For Employees with a Qualifying Life Event Only
87 KEnglish

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