Flexible Spending Account Election

For Employees with a Qualifying Life Event Only

PLEASE NOTE:

 Flexible spending account (FSA) enrollments are completed each fall during Open Enrollment through the Benefits Enrollment System. This form is to be used only by employees who have experienced a qualifying life event. If you have experienced a qualifying life event and wish to enroll in an FSA for 2024, complete the form below and return it to the Employee and Retiree Service Center. 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 submit your elections via one method only. 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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