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E.FLEXIBLE SPENDING ACCOUNTS <br /> V. 0 Other: <br /> d. Adoption Assistance Flexible Spending Account: <br /> i. 0 None <br /> ii. 0 Discretionary <br /> iii. 0 %of the Participant's Compensation <br /> iv. 0 $ per Eligible Employee <br /> v. 0 Other: <br /> NOTE:If there are no non-elective Employer contributions, questions under E.2 are disregarded. <br /> NOTE:Employer matching and non-elective contributions shall not exceed the limits set forth in the BPD including: <br /> Health FSA,Section 6.04(b); HSA-Compatible FSA Section 7.04; Dependent Care Assistance Plan Account Section <br /> 8.04; and Adoption Assistance Flexible Spending Account, Section 10.04. <br /> NOTE:If the Plan is intended to be a simple cafeteria plan, the Employer non-elective contributions in this section <br /> will apply in addition to the contributions at A.6b. <br /> 3. Contribution Limits. Select the maximum allowable Participant contribution to the applicable FSA in any Plan Year: <br /> a. Q The maximum amount permitted under Code section 125(i), ), 129(a)(2) and/or 137(b)(1) <br /> b. 0 Other amounts <br /> i. Health Flexible Spending Account: <br /> ii. Limited Purpose/Post-Deductible Health Flexible Spending Account (HSA-Compatible FSA): <br /> iii. Dependent Care Assistance Plan Account: <br /> iv. Adoption Assistance Flexible Spending Account: <br /> NOTE:Other amounts for Health Flexible Spending Account in E.3bi and Limited Purpose/Post-Deductible Health <br /> Flexible Spending Account in E.3ii cannot exceed the Code section 125(i)maximum. Other amounts in E.3b.iii for <br /> Dependent Care Assistance Plan Account cannot exceed Code 129(a)(2) amounts and E.3b(iv)cannot exceed Code <br /> section 137(b)(1) maximum. <br /> Eligible Expenses <br /> 4. Individual Expenses Eligible for Reimbursement. Participant may only be reimbursed from the applicable FSA for <br /> expenses that are incurred by: <br /> a. Q Participant, spouse and Dependents.The Participant, his or her spouse and all Dependents, and any child <br /> (as defined in section 152(f)(1)) of the Participant until his or her 26th birthday: <br /> b. 0 Persons covered under Employer-sponsored group health plan.The Participant, his or her spouse and all <br /> Dependents, and any child (as defined in section 152(f)(1)) of the Participant until his or her 26th birthday, but <br /> only if such persons are also covered under an Employer-sponsored health plan: <br /> c. 0 Participants only. No reimbursement for expenses incurred by the Participant's spouse or Dependents: <br /> d. 0 Other: (may not include anyone other than the Participant, his or her spouse and all Dependents, <br /> and any child (as defined in section 152(f)(1)) of the Participant until his or her 26th birthday) <br /> Expenses Not Eligible for Reimbursement <br /> 5. Expenses Not Eligible for Reimbursement. In addition to those listed in the Basic Plan Document, the following <br /> expenses are not eligible for reimbursement from a Participant's FSA: <br /> a. 0 Health Flexible Spending Account: <br /> b. 0 Limited Purpose/Post-Deductible Health Flexible Spending Account (HSA-Compatible FSA): <br /> c. 0 Dependent Care Assistance Plan Account: <br /> d. 0 Adoption Assistance Flexible Spending Account: <br /> 6. Adult Children Coverage. Reimbursement for adult children may be paid from the applicable FSA for claims <br /> 8 Copyright©2002-2018 <br /> Benefit Plans Administrative Services LLC <br />