Flex Spending Account enrollment and calculation

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Flexible Spending Account
 Deduction Worksheet
 This worksheet will help you calculate your applicable expenses and how
 much money would be in an FSA deduction each pay period.

 Medical/Dental/Vision Reimbursement Account
  Annual Medical Expenses, such as:
  Deductibles and co-pays             $ _____________
  Routine physical exams              $ __________140
  Prescriptions                       $ _____________
  Chiropractic care                   $ _____________
  Gastroenterologist                  $ _____________
  Podiatrist                          $ _____________
  Ophthamologist                      $ __________140
  Audiologist                         $ __________140
  Other                               $ _____________
 Annual Dental Expenses, such as:
  Deductibles and co-pays             $ _____________
  Routine check-ups                   $ __________280
  Orthodontia                         $ _____________
  Other                               $ _____________
 Annual Vision Care Expenses, such as:
  Exams                               $ __________140
  Eyeglasses                          $ __________420
  Contact lenses, solutions, cleaners $ _____________
  Other                               $ _____________
 Slush                                $ __________500
 Rolled Over from Last Year           $ _____________
 Total Estimated                      $ _________1760
 Medical/Dental/Vision Expenses
   $ _____________ + _________________  = $ __________
     Annual Amount   # of Pay Periods*     Per Pay Period
     (cannot exceed
      company max.)

 *Weekly, 52 pay periods Biweekly, 26 pay periods Semimonthly,
  24 pay periods Monthly, 12 pay periods