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Home My WebLink About2014 Flex Enrollments S stem- ILTASC IN, Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name KEN ANDERSON Address 1508 DRIVING PARK RD. City STILLWATER State MN Zip 55082 Email krander @cityofoakparkheights.com Home Phone Number 651-430-2823 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction A ount Medical(Out-of-Pocket)Expenses $2,500.00 $ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappro riate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. 7:14! Authorize Signature . ; Date: N x'01 TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 ... i" TAS FlexSyste I1 Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted. Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name GARY BRUNCKHORST Address 504 TRILLIUM LANE City HUDSON State WI Zip 54016 Email g-brunckhorst@att.net Home Phone Number 715-386-1064 Mobile Phone Number 651-260-4087 Participant's Plan Effective Date 1-1- \�1 Date of First Payroll 1-1S- iy Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Signature U Date: „— TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 FiexSystem- Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name BETTY CARUSO Address 1128 THIRD STREET City HUDSON State WI Zip 54016 Email bcaruso @cityofoakparkheights.com Home Phone Number -- Mobile Phone Number 715-781-7152 Participant's Plan Effective Date 1 , Date of First Payroll L k t s l 1 y Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $_ ( (,Q (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ �� Non-Employer Sponsored Premiums No Maximum $ /- Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7— 10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name (Last,First, MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Signature � Date: 1111 �' 13 TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 FlexSystem- tu, ilLTASC Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name JOSEPH CROFT Address 22867 PERKINS AVE. NO. City SCANDIA State MN Zip 55073 Email crftj @yahoo.com Home Phone Number 651-433-2330 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ $O437 (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Signature "t Date: I/--•2 ri-/3 TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661•Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 FiexSystem- Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name BRIAN DEROSIER ` Address / %�7v°L t�/� �/�4 (t /e City OAK PARK HEIGHTS State MN Zip 55082 Email bwderos @cityofoakparkheights.com Home Phone Number -- 117-- </F5-- a3(9 7 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ rt'/ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Signature -� `" ---� Date: //// /3 TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 FlexSystem-,IL Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name JONATHAN GIVAND Address 2967 GALTIER STREET City ROSEVILLE State MN Zip 55113 Email lgivand @cityofoakparkheights.com Home Phone Number -- Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ d Non-Employer Sponsored Premiums No Maximum $ U Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transacti• 4 ncurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudule -of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Signature Date: /1_ TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 ..r. .fir, .0 I. 1 .�`�► ly Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name JULIE HULTMAN Address 2005 STATE RD. 35 City SOMERSET State WI Zip 54025 Email jhultman@hotmail.com Home Phone Number 715-247-4070 Mobile Phone Number 651-398-4590 Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ 1300 (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ Non-Employer Sponsored Premiums No Maximum $ O Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for jcyour spouse or dependent,print their name below.Cards are mailed to your home address 7----- 10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last, First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Signatur•_' '........._., .. Date: 21 j_ TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 • Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091 1 12 S Stem ' 11 1 OAS C 41111i. 41111 Y il ... Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name ERIC JOHNSON Address 620 OAKWOOD ST S City BAYPORT State MN Zip 55003 Email eajohnson @cityofoakparkheights.com Home Phone Number 651-253-7837 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ $5:3(' (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 Al , 0 0 0 Non-Employer Sponsored Premiums No Maximum $ , Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): -3-0K NS o m , �Ql L , A . AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to hav- /eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TA • •..• issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all res.ans..r for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that up. in... •.riate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Signatur- � / Date: )A- -13 TASC•231/ w International Lane•Madison,WI 53704-3140. 1-800-422-4661•Fax:608-245-3623• ww.tasconline.com The information in this co lunication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 41.11. 411111■ - Flex5 stem Y �I „LTA S C Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name ANDREW KEGLEY Address 406 WACOUTA ST LOFT 703 City ST. PAUL State MN Zip 55101 Email akegley @cityofoakparkheights.com Home Phone Number 651-334-5140 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ Non-Employer Sponsored Premiums No Maximum $ 0 Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to hay;my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC . ds issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsi- lity for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inap ropriate or fraudulent use of e TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Signature Date: l I Z 1 ` 3 TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661•Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091 1 1 2 4111116 4111111h, F1exSystem Client TASC ld: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form. Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 � Participant Information: Full Name DAVE KISCH f 15? �r2°lLr�€ ,4'.e ✓�•! Address _,4342-V4 A3 I-#t7 City HUGO State MN Zip 55038 Email drkisch @cityofoakparkheights.com Home Phone Number 651-334-7173 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ . Non-Employer Sponsored Premiums No Maximum $ �� Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7— 10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name (Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate cy atihtlent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Signature t Date: Z Ul�1 TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. Px-2008-09I 112 I Flex System- , "MSC Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name FRED KROPIDLOWSKI Address 2676 BRITTANY LANE City WOODBURY State MN Zip 55125 Email fjkropi @cityofoakparkheights.com Home Phone Number 651-730-5859 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ — 0 — (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ U Non-Employer Sponsored Premiums No Maximum $ V Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): `i re P lc; ow s L-s- su.j r r r e AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately retum all TASC Cards to my Employer. Authorize Signatur• 1 Date: I ( J o//3 TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661•Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 ' cS y stem ' Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name SANDRA KRUSE-ROSLIN Address 2615 FAIRLAWN DRIVE City STILLWATER State MN Zip 55082 Email skkruse @cityofoakparkheights.com Home Phone Number 651-275-1562 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ 4 0 0 . 0 0 (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ 14 8 0 . 0 0 Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below. Cards are mailed to your home address 7— 10 days after your enrollment has been updated in FlexSystem. . Spouse or Dependent Name (Last,First, MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Si g nature Date: I TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 air FlexSystem-stem- Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name Li na_c Mane Puem t 5� Address (pZL{O iecunk Pr City 4v+cf(L State y Zip SS I?_ Email iikascy.pacacetkOphoo cor " Home Phone Number Mobile Phone Number 703-4 t Z- ZS Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions on page 2. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Election Medical(Out-of-Pocket)Expenses $2,500.00 $ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Signature 00' Date: 13 TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 TM �'TAS FIexS stem y 1I K. Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name JENNIFER PINSKI Address 1656 ROLLING HILLS LANE City RIVER FALLS State WI Zip 54022 Email Jpinski @cityofoakparkheights.com Home Phone Number 715-338-1322 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ 4 C C 00 (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $4 Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7— 10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappiopriate or fraudule u of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. ( r ( Authorize Signature ^It Y. _ N„ Date: k t l t 2 f I tF) TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 FIexSystemM 11TASc,w Flexible Spending Account Enrollment Form 42011 6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name MARK ROBERTSON Address 10860 68TH ST. SO. City COTTAGE GROVE State MN Zip 55016 Email mrobertson @cityofoakparkheights.com Home Phone Number 651-455-0050 Mobile Phone Number — Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ 0 Non-Employer Sponsored Premiums No Maximum $ C/ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card' s ctions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon in . opria : .udul- of the TASC Card or termination of employment,I will immedi. ly return al TASC Cards to my Employer. Authorize Signature ;,, / Date: P2 a/3 TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661•Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 AMY, 1,�, 1► S st Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name I r \(`,S'\ 342,. 9 e, Address (,p'1 3 L .ci(P QI dqe. City t,J0OA90t. State)y(1) Zip 55(,).5 Email M 5e� e t`@ r oc Call-F°`r e`qtj tS. corn Home Phone Number 4031 ' v 9 7`7 Mobile Phone Number (p5( a71 /11f`f Participant's Plan Effective Date l — 1- a01 L{ Date of First Payroll j— 1 rj- f L, Prior to completing your election amounts,refer to the instructions and frequently asked questions on page 2. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Election Medical(Out-of-Pocket)Expenses $2,500.00 $ 0 (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7— 10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name (Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending accounts) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. ,Ii � Authorize Signature u Y l � Date: I ^ 1 c - G "�'1`/ do�. ) TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. i i i 112 FlexSystem- 1111! TASC Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name ANDREW SWENSON Address 14846 UPPER 55TH ST. NO. City OAK PARK HEIGHTS State MN Zip 55082 Email aswenson @cityofoakparkheights.com Home Phone Number -- Mobile Phone Number — Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ 0 Non-Employer Sponsored Premiums No Maximum $ 0 Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Signature Date: 'i I�1 ) 3 TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661•Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 ,..k V.i.A,:',. , , ir p-L;;,,,, ,.:,,, ,, 12 0, . , „I-( ystern- Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park I Ieights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name JUDY TETZLAFF Address 5059 GRENADIER AVE. NO. City OAKDALE State MN Zip 55128 Email Home Phone Number 651-770-7765 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7- 10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upop inappropriate or fr udulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. ? _,1 Authorize Signature :,`� f (t>`t- . Date: /1//j .. Pr TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. Fx-2008-091 1 12 i I LTA S C Xs System " Flexible Spending Account Enrollment Form 42011 6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name CHRISTOPHER VIERLING Address 1333 SOUTH 5TH STREET City STILLWATER State MN Zip 55082 Email cvierling @cityofoakparkheights.com Home Phone Number 651-739-8295 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): \ la'i j wC ,A 1115°1'1 M AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. --- Authorize Signature Date: 1'f 19/i3 TASC•2302 International Lane•Madison,WI 53704-3140.1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112 FlexSysterrr Client TASC Id: Flexible Spending Account Enrollment Form 4201-6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted. Make P.O. BOX 2007 sure to sign and date the enrollment form. Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name DAVID WYNIA Address City J..AI4E-ELMO yLrak/ak a State MN Zip 6042 53767 Email dwynia @cityofoakparkheights.com Home Phone Number -- Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical (Out-of-Pocket)Expenses $2,500.00 $ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ $- Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional'TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7-10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsibility for card transactions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that upon inappropriate or fraudulent use of the TASC Card or termination of employment,I will immediately return all'TASC Cards to my ISmployer- Authorize Signattyaf( Date: /9 -1— / 3 l � TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661•Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. F x-200 8-091 112 ' e S stem- .. ..T C Flexible Spending Account Enrollment Form 42011 6844-0484 Plan Name: City Of Oak Park Heights GARY BRUNCKHORST Every line must be completed.Please enter zero(0)on CITY OF OAK PARK HEIGHTS the lines where no amount is being deducted.Make P.O. BOX 2007 sure to sign and date the enrollment form.Return the 14168 OAK PARK BLVD. NO. completed and signed form to your employer. OAK PARK HEIGHTS MN 55082 Participant Information: Full Name BRIAN ZWACH Address 647 CROIXWOOD PL City STILLWATER State MN Zip 55082 Email bzwach @cityofoakparkheights.com Home Phone Number 651-336-7627 Mobile Phone Number -- Participant's Plan Effective Date Date of First Payroll Prior to completing your election amounts,refer to the instructions and frequently asked questions. Benefit Maximum Employee Annual Salary Salary Reduction Reduction Amount Medical(Out-of-Pocket)Expenses $2,500.00 $ (For plan start dates in 2013,employee annual salary reductions may not exceed$2,500.) Dependent Care Expenses $5,000.00 $ Non-Employer Sponsored Premiums No Maximum $ Additional TASC Card for Spouse or Dependent Each participant may receive one additional card for their spouse or dependent free of charge.To request an additional TASC Card for your spouse or dependent,print their name below.Cards are mailed to your home address 7—10 days after your enrollment has been updated in FlexSystem. Spouse or Dependent Name(Last,First,MI): AUTHORIZATION:I certify the above information to be true to the best of my knowledge and that the children for whom I will be claiming dependent or child care expenses either reside with me in a parent-child relationship or are legally dependent on me for their support.I agree to have my compensation reduced by the deduction amount(s)stated above.I understand amounts remaining in my flexible spending account(s)not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws.I further understand the Flexible Spending Amount will be in effect for the entire plan year and cannot be changed or revoked except as permitted by federal law.I understand my share of eligible group premium(s)will be automatically deducted before taxes. I also understand,that if I do not wish to have my eligible insurance contributions deducted pre-tax and prefer to be taxed on these dollars,I will contact my payroll department.I understand additional TASC Cards issued to my spouse or dependent will provide the named individual with access to my flexible spending account(s) and MyCash account.I accept all responsib' • or c. = sa•ions incurred by the named individual and will submit supporting documentation,as requested,for those transactions.I agree that u.. • appro.,:e or fraud - t.se of the TASC Card or termination of employment,I will immediately return all TASC Cards to my Employer. Authorize Sig : ure �� ti Date: /2 /- /5 TASC•2302 International Lane•Madison,WI 53704-3140. 1-800-422-4661 •Fax:608-245-3623•www.tasconline.com The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose.Any other use or disclosure is prohibited. FX-2008-091112