Employee Signature
I, the undersigned, hereby revoke any and all previous account elections under the Plan and authorize my employer to reduce my cash compensation by deducting, on a pre-tax basis, the amounts elected above. I understand and agree that:
1) the deductions will continue through the end of the applicable Plan Year or the termination of my employment and cannot be changed unless I incur a qualifying change in status event. The amounts I have elected will be available to me for the reimbursement of qualifying expenses according to, and for the period specified in, my employer's Plan Document.
2) I have read and agree to comply with the Internal Revenue Code Regulations and other Plan rules and provisions at the link below. I understand that my employer's Plan Document contains the controlling terms and provisions by which the operations of the Plan are governed.
3) in the event that any reimbursement I may claim and receive under the Plan is later deemed unsubstantiated by the IRS, I hereby acknowledge and accept responsibility, and hold my employer and SuperiorUSA harmless, for any adverse tax consequences that may result. Furthermore, I will notify my employer if I have reason to believe that any reimbursement I receive was for a non-qualified expense.
Please click the link below for additional information regarding your Flex Elections.