Dependent Care Reimbursement Plan (D-Care Plan)

Enrollment Form - Print, Fill Out and Return to Personnel Department

D-CARE ENROLLMENT FORM

I hereby elect to participate in the County of Santa Cruz Flexible Spending Program Amended and Restated Dependent Care Reimbursement Program ("D-Care Plan") and I request and authorize that the amount of $______ be withheld from each of my bi-weekly paychecks during the Plan Year for the purpose of funding my dependent care assistance account. I understand that this salary reduction will be effective beginning Pay Period One (12/22/01-01/04/02) in Calendar Year 2002, or if I am hired after Pay Period One in Calendar Year 2002, this salary reduction will be effective the pay period following my first pay period of employment with the County of Santa Cruz ("County") and will remain in effect until the last Pay Period of Calendar Year 2002 (12/07/02-12/20/02).

I understand that:

-- Unless there is a change in my family status specifically provided for in the D-Care Plan, I cannot change or revoke this benefit election prior to the beginning of the next plan year.

-- I must submit claims for reimbursement of all eligible expenses prior to January 31, 2003. Any funds remaining in my dependent care assistance account as of January 31, 2003 will be forfeited to the County and will not be refunded to me.

-- These dependent care expenses may not be used to claim any Federal income tax deduction or credit (including the dependent care tax credit). I agree to file IRS Form 2441 with my tax return and provide the name, address, social security number or taxpayer identification number for all dependent care providers (persons or organizations) on my federal income tax return.

-- Prior to the beginning of each plan year, I will be required to re-elect my coverage under the D-Care Plan for the following plan year. If I do not complete and return a new election form at that time, I will have elected no coverage for the following plan year.

PLEASE PRINT:

Employee Name: _______________________________________

Home Address: ____________________________________________

Social Security Number: _______________________
Employee Number: _______________

SIGNATURE: ___________________________________
Date: _____________________

PLEASE RETURN THIS FORM TO THE AUDITOR CONTROLLER'S OFFICE
454-2665

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