Forms → Staff → Benefits → Flexible Spending Account Calendar Year 2021 Election

Flexible Spending Account Calendar Year 2021 Election

For Employees with a Qualifying Life Event Only

About this Form

Form number: 450-3

Audience:  MCPS Staff

Last revised: January 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 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 e-mail 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.

Adobe PDF Flexible Spending Account Calendar Year 2021 Election
For Employees with a Qualifying Life Event Only		471 KEnglish

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