Re: Flex Spending Account enrollment

[http://dummy.us.eu.org/robert (Robert)]

I pasted the text version of the form below, for convenience.

I'll send you my numbers after I calculate 'em.

Paychex
 Flexible Spending Account
 Deduction Worksheet
NOTE: This is not an enrollment form. This worksheet is intended to guide
you through the enrollment process.
 This worksheet will help you calculate your applicable expenses and how
 much money would be in an FSA deduction each pay period.

 Medical/Dental/Vision Reimbursement Account
  Annual Medical Expenses, such as:
  Deductibles and co-pays             $ _____________
  Routine physical exams              $ _____________
  Prescriptions                       $ _____________
  Chiropractic care                   $ _____________
  Other                               $ _____________
 Annual Dental Expenses, such as:
  Deductibles and co-pays             $ _____________
  Routine check-ups                   $ _____________
  Orthodontia                         $ _____________
  Other                               $ _____________
 Annual Vision Care Expenses, such as:
  Exams                               $ _____________
  Eyeglasses                          $ _____________
  Contact lenses, solutions, cleaners $ _____________
  Other                               $ _____________
 Total Estimated
 Medical/Dental/Vision Expenses
   $ _____________ + _________________  = $ __________
     Annual Amount   # of Pay Periods*     Per Pay Period
     (cannot exceed
      company max.)

 *Weekly, 52 pay periods Biweekly, 26 pay periods Semimonthly,
  24 pay periods Monthly, 12 pay periods

 FSA009 8/05