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Flexible Spending Account Election

For Employees with a Qualifying Life Event Only

About this Form

Form number: 450-3

Audience:  MCPS Staff

Last revised: November 2022

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 (FSA) for 2023, 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.

To make an adjustment to your 2022 FSA, please use this version of the form.

 

Adobe PDF Flexible Spending Account Election
For Employees with a Qualifying Life Event Only		92 KEnglish

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