I understand that:

Medical reimbursements will be available only for "qualifying health care expenses" for my qualifying dependents and myself as described in the Summary Plan Description.

Dependent care reimbursements will only be available for "qualifying dependent care expenses" as described in the Summary Plan Description. I agree to provide the claims administrator with the name, address, and taxpayer identification number of the dependent care service provider.

I agree to notify the Employer if I have reason to believe that any expense for which I have obtained reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Employer for any liability it may incur for failure to withhold federal, state, or social security tax from any reimbursement of a non-qualifying expense, up to the amount of additional tax actually owed by me.

I cannot change or revoke this election any time during the Plan Year unless it is on account of and consistent with a change in status as described in the Summary Plan Description and allowed under current Internal Revenue Code Section 125 regulations.

Any expenses paid through the plan may not be used as a credit or deduction on my federal tax return.

The amount of my compensation redirection shall be credited to a health care reimbursement and/or dependent care reimbursement account and I will be reimbursed for the applicable expenses incurred during the year.

My social security benefits may be slightly reduced as a result of my election.

Amounts that are not claimed for expenses incurred during the Plan Year coverage period will be forfeited and may not be paid to me in cash or carried over for expenses incurred after the Plan Year coverage period.

THIS AGREEMENT IS SUBJECT TO THE TERMS OF THE EMPLOYER'S HEALTH CARE REIMBURSEMENT PLAN AND/OR DEPENDENT CARE PLAN AS AMENDED FROM TIME TO TIME IN EFFECT, SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH APPLICABLE LAWS, SHALL TAKE EFFECT AS A SEALED INSTRUMENT UNDER APPLICABLE LAWS, AND REVOKES ANY PRIOR ELECTION AND COMPENSATION REDIRECTION AGREEMENT RELATING TO SUCH PLAN(S). I UNDERSTAND AND AGREE THAT BY COMPLETION OF THIS ELECTION BY CLICKING THE “SUBMIT” BUTTON, I HAVE AGREED TO THE ELECTIONS MADE UNDER THIS PLAN AND AM BOUND BY THE TERMS AND CONDITIONS OF THE PLAN.