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Employee ID Number: HEALTH CARE & DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS Enrollment Form Name: Last, First, Middle Initial SSN # Street Address DOB City State Zip Code Based on your estimates, elect the amount you wish to contribute to the Health Care Spending Account and/or the Dependent Care Spending Account this year. HEALTH CARE ACCOUNT Per Pay Period Amount Annual Goal Amount DEPENDENT CARE ACCOUNT Per Pay Period Amount Annual Goal Amount The IRS has established annual limits that can be contributed to the Dependent Care Spending Account. ($5000 or $2500 if married and filing a separate income tax return) I authorize the reduction of my salary on a per paycheck basis, by the amount designated above. I understand that the amounts deducted from my pay and not used for eligible health care or dependent care expenses incurred in the same year, will be FORFEITED in accordance to IRS regulations. I also understand that this authorization is irrevocable until the next election period unless I have a change in family status as defined by the IRS and Columbia County. Signature Date