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E.FLEXIBLE SPENDING ACCOUNTS <br /> ii. 0 Discretionary <br /> iii. 0 %of the Participant's Health FSA contribution up to %of the Participant's Compensation <br /> iv. 0 %of the Participant's Health FSA contribution up to $ <br /> v. ❑ Other: <br /> b. Limited Purpose/Post-Deductible Health Flexible Spending Account(HSA-Compatible FSA) <br /> i. ❑ None <br /> ii. ❑ Discretionary <br /> iii. ❑ %of the Participant's HSA-Compatible Health FSA contribution up to %of the <br /> Participant's Compensation <br /> iv. 0 %of the Participant's HSA-Compatible Health FSA contribution up to$ <br /> v. ❑ Other: <br /> c. Dependent Care Assistance Plan Account: <br /> i. 0 None <br /> ii. 0 Discretionary <br /> iii. 0 %of the Participant's DCAP Account contribution up to %of the Participant's <br /> Compensation <br /> iv. 0 %of the Participant's DCAP Account contribution up to$ <br /> v. 0 Other: <br /> d. Adoption Assistance Flexible Spending Account: <br /> i. ❑ None <br /> ii. ❑ Discretionary <br /> iii. ❑ %of the Participant's Adoption Assistance FSA contribution up to %of the Participant's <br /> Compensation <br /> iv. ❑ %of the Participant's Adoption Assistance FSA contribution up to$ <br /> v. ❑ Other: <br /> NOTE:If there are no Employer matching contributions to the Plan, questions under E.1 are disregarded. <br /> NOTE:Only one contribution formula is permitted for each applicable Benefit. <br /> NOTE:If the Plan is intended to be a simple cafeteria plan, the matching contributions in this section will apply in <br /> addition to the contributions at A.6b. <br /> 2. ❑ Non-Elective Employer Contributions.The Plan permits Employer contributions to the applicable Benefits as <br /> follows: <br /> a. Health Flexible Spending Account: <br /> i. ❑ None <br /> ii. 0 Discretionary <br /> iii. ❑ %of the Participant's Compensation <br /> iv. ❑ $ per Eligible Employee <br /> v. ❑ Other: <br /> b. Limited Purpose/Post-Deductible Health Flexible Spending Account(HSA-Compatible FSA): <br /> i. ❑ None <br /> ii. ❑ Discretionary <br /> iii. ❑ %of the Participant's Compensation <br /> iv. 0 $ per Eligible Employee <br /> v. ❑ Other: <br /> c. Dependent Care Assistance Plan Account: <br /> i. ❑ None <br /> ii. 0 Discretionary <br /> iii. 0 %of the Participant's Compensation <br /> iv. ❑ $ per Eligible Employee <br /> 7 Copyright©2002-2018 <br /> Benefit Plans Administrative Services LLC <br />