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Employer Contributions? 0 No ❑ Yes Payroll/Funding Cycle (select one): ❑ Weekly ❑ Bi -Weekly 0 Semi -Monthly ❑ Monthly ❑ Other: _ 9 Contributions in 12 -mo Plan Year: Participant Contribution Schedule: Dates applied to Participant, accounts based -a - n above selected payroll cycle. (based on Plan Funding schedule below for Y` Contribution: __I 21° Contribution ��J— Last Contribution I ) zJZi7 the Estimated Date of Recelpt (EDR)) Other cvdes: Entry and Probationary Period: Selectthe employment requirement below that an eligible employee must meetin order to enroll in the FlexSystem Plan at open enrollment, or atthe time of hire: ❑ On the date of hire ❑ 1" of the month after date of hire ER 30 days after date of hire ❑ 1" of the month after 30 days of continuous employment ❑ 60 days after date of hire ❑ 1" of the month after 60 days of continuous employment ❑ 90 days after date of hire ❑ Other: ._._included Excluded NA_..,� ❑ ❑ O Members of bargaining units Additional Requirements: (selectallthatapply) ❑ — 0 E Part-time employees regularly scheduled to work at,least—hours perweek ❑ ❑ ❑O - Seasonal employees regularly working at least. months within a year ❑ ❑ ❑O ( Emolovees under vears of a¢e This Section defines the Estimated Claims Fee (ECF) method utilized to make benefit payments to your FlexSystem Participants. The ECF Is calculated by determining the total contributions for the Plan Year (employee and employer) and divide that total by the number of payments scheduled under the Expected Date of Recelpt (EDR). This fee Is adjusted as applicable for mid -year enrollment and election changes. If the total ECF collected for the Plan Year results in excess fees greater than paid claims for that Plan Year, the excess will be returned to the Plan Sponsor as forfeiture under the Plan. Any fees or charges described in this section are in addition to the fees due under Part 2: TASC Services and F,�. To start this rocess: (1) ch000se funding process, (2j vert your Expected Date of Receipt, and (3) enter your bank Information: —...�._--_.__..�....___.__.___._ __...___..._._... (1) ! U TASC ACH (default): TASC Initiates funding payment via ACH on the EDR. ❑ Client MyTASC Funding: Clientinitiates funding payment via MyTASC on orbefore the EDR.Note: Under this option, TASC will use yourAccount and Routing Numbers To post any unpaid funding amounts that are one (1) business day past the EDR. Also, additional annual fee will apply If ACH Is not elected ($10.00per payroll). (2) Verify your Expected Date EDR is the payroll contribution schedule Indicated in the Plan Contribution section for each payroll cycle. This Is the date of Receipt (EDR): that TA5Cw1ll pull an Auto ACH from your designated account and apply the payroll contributions to your Participant's _ accounds). This may ormaynot he the same date as the Partic)pant's payrof) deduction date. (3) Bank Information: ❑ Use same ACH info from Part 4 of this Application ❑ Use different ACH information as per below: Financial Institution Name: State: Bank Routing Number (9 digits): Checking Account 9: ADMIN ONLY: FlexSystem - Special Instructions: Page Employerinitialy/ ��{'T�iSC TC,3923-010117 b-----