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Change Carryover - Effective Immediately for the 2023 Plan Year <br />1. Choose the account options to which current carryover rules will be adjusted. Note: carryover cannot be <br />added to a plan that has the 2.5 month grace period. By checking any of the below options, you are agreeing to <br />remove the 2.5 month grace period if that feature is part of the current plan design. Changes will apply to future <br />plan years and will not impact any current plan year functionality. <br />❑X Health FSA <br />❑ Limited Purpose Health FSA <br />2. Designate carryover amount. <br />x❑ Maximum available at this time. If selected, consider automatically updating the maximum value each year. <br />A fee of $50 will apply annually when adjustments are needed. This fee will not be charged if you have already <br />elected to have the FSA maximum contribution amount automatically update. The fee covers plan amendments, <br />system updates and new custom enrollment flyers. ❑x Yes ❑ No (',current set up) <br />❑ Othervalue: <br />3. Add or change minimum carryover value (optional). Designate minimum value (if left blank, no minimum value <br />will be enforced): <br />4. require re-ennAlment in the new plan year in order to receive carryover funds. <br />0 Yes (add) <br />❑ No (remove) <br />SOW: Carryover: Page 2 <br />(•� <br />1VjE <br />© Igoe Administrative Services 2021 <br />