Common use of AUTHORIZATION AND ACKNOWLEDGEMENT Clause in Contracts

AUTHORIZATION AND ACKNOWLEDGEMENT. I understand that I cannot revoke or change this election during the year unless there is a qualifying "Status Change". The requested election change must be consistent and in line with the qualifying event (QLE). I may then revoke my prior election and sign a new Agreement if such a change occurs. QLEs include a change in your legal marital status, birth of a child, date you adopt a child, death of spouse or dependent, loss of employment, or your child reaches the age 13 or change in child care services. Changes must be submitted within 30 days of the qualifying life event (QLE). I understand that when I submit a claim, I must include appropriate documentation (e.g. explanation of benefits from my Insurance Provider, itemized bill, etc.) for out-of-pocket Medical, Dental, Vision expenses before I can be reimbursed. I hereby elect to participate in Flexible Spending Account as indicated on this form. I authorize Plainview-Old Bethpage CSD to make pretax deductions from my salary on the payroll schedule I have elected above.

AUTHORIZATION AND ACKNOWLEDGEMENT. I understand that I cannot revoke or change this election during the year unless there is a qualifying "Status Change". The requested election change must be consistent and in line with the qualifying event (QLE). I may then revoke my prior election and sign a new Agreement if such a change occurs. QLEs include a change in your legal marital status, birth of a child, date you adopt a child, death of spouse or dependent, loss of employment, or your child reaches the age 13 or change in child care services. Changes must be submitted within 30 days of the qualifying life event (QLE). I understand that when I submit a claim, I must include appropriate documentation (e.g. explanation of benefits from my Insurance Provider, itemized bill, etc.) for out-of-pocket Medical, Dental, Vision expenses before I can be reimbursed. All eligible expenses/claims must be incurred during the time that I participate in the plan in order to be eligible for reimbursement. I hereby elect to participate in Flexible Spending Account as indicated on this form. I authorize Plainview-Old Bethpage CSD to make pretax deductions from my salary on the payroll schedule I have elected above.. Employee's Name Date:

AUTHORIZATION AND ACKNOWLEDGEMENT. I understand that I cannot revoke or change this election during the year unless there is a qualifying "Status Change". The requested election change must be consistent and in line with the qualifying event Qualifying Life Event (QLE). I may then revoke my prior election and sign a new Agreement if such a change occurs. QLEs include a change in your legal marital status, birth of a child, date you adopt a child, death of spouse or dependent, loss of employment, or your child reaches the age 13 or change in child care childcare services. Changes must be submitted within 30 days of the qualifying life event (QLE). I understand that when I submit a claim, I must include appropriate documentation (e.g. explanation of benefits from my Insurance Provider, itemized bill, etc.) for out-of-pocket Medical, Dental, Vision expenses before I can be reimbursed. I hereby elect to participate in Flexible Spending Account as indicated on this form. I authorize Plainview-Old Bethpage CSD to make pretax deductions from my salary on the payroll schedule I have elected above.

AUTHORIZATION AND ACKNOWLEDGEMENT. I understand that I cannot revoke or change this election during the year unless there is a qualifying "Status Change". The requested election change must be consistent and in line with the qualifying event (QLE). I may then revoke my prior election and sign a new Agreement if such a change occurs. QLEs include a change in your legal marital status, birth of a child, date you adopt a child, death of spouse or dependent, loss of employment, or your child reaches the age 13 or change in child care childcare services. Changes must be submitted within 30 days of the qualifying life event (QLE). I understand that when I submit a claim, I must include claim and appropriate documentation (e.g. explanation of benefits from my Insurance Provider, itemized bill, etc.) for out-of-pocket Medical, Dental, Vision expenses before I can be reimbursed. I hereby elect to participate in Flexible Spending Account as indicated on this form. I authorize Plainview-Old Bethpage CSD Xxxxxxxxx XXXX to make pretax deductions from my salary on the payroll schedule I have elected above.