Flexible Spending Account Election Form

Employee Information

Employee Name:

John Carter

Employee ID:

DRV-001

Address:

1240 W 6th St, Cleveland, OH 44113

Phone:

206-667-3424

Email:

jcarter@yahoo.com

Health Care Flexible Spending Account (FSA)

Health Care FSA Election:

Health Care FSA — Annual Election Amount

Declined

Coverage Type	Election	Annual Election Amount	Per Pay Period (26)
Health Care FSA	Elected	$2984.54	$114.79

Dependent Care Flexible Spending Account

Dependent Care FSA Election:

Dependent Care FSA — Annual Election Amount

Waived / Source deduction not found

Coverage Type	Election	Annual Election Amount	Per Pay Period (26)
Dependent Care FSA	Waived	$0.00	$0.00

Payroll Deduction Authorization

I hereby authorize Delta Advanced Trucking, Inc. to deduct elected FSA contributions from my payroll checks on a per-pay-period basis. I understand that these deductions will continue until I submit a written change request during annual open enrollment period or due to a qualifying life event. I certify that the FSA contributions will be used for eligible health care and/or dependent care expenses as defined by IRS Section 125.

Employee Certification: I understand that unused FSA funds at year-end will be forfeited according to IRS regulations and company policy.

Employee Signature

John Carter

Date:

2025-11-10

Employee Name (Print): John Carter

HR/Benefits Review

M. Torres

Date:

2025-11-11

HR Representative: M. Torres

Relationship Note: This form connects to payroll deduction worksheet and annual FSA contribution tracking.