FSA Waiver | IntegraFlex

Note: This form is completed when an eligible participant is "Waiving" their participation in their company Flexible Spending Account (FSA).

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Employer Information

Company Name**

Plan Effective Date**

Employee Information

First Name**

M.I.

Last Name**

Social Security Number**

Date of Birth**

Note: Your personal information and email are kept private/secure within IntegraFlex's system. The information that you provide is used to identify you within our system. We DO NOT disseminate to any Third Party's unless we have your specific written consent. We solely use your email for communication purposes with IntegraFlex.

PLEASE READ AND INITIAL THE FOLLOWING WAIVER STATEMENT

By signing this Waiver, I certify that the features and benefits under a 125 Flexible Benefits Plan have been explained to me. I am electing to Waive all pre-tax benefits under the plan on or after the first day of the plan year and understand that I cannot change or revoke this Waiver and may be prohibited from participation in this plan until the open enrollment period for the following year or unless I have had a Qualifying Event (May include: marriage, birth, adoption, divorce or death), as defined by the IRS.

Please Initial**

Notes

Note: Please provide us with your best contact number and email address, so we may contact you regarding your account, if needed.

Best Contact Number**

Email address**

Type Full Signature**

Date of Signature

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