Employer Name:

Plan Year: January 1, 2004 to December 31, 2004

Name: SS# - -

Address:

City: St: Zip:

Date of Birth: Date of Hire: HmPh:

E-Mail:

Position:

On separate benefit enrollment form(s), I have enrolled for certain insurance coverage(s) and understand that an amount equal to the total amount of premium for coverage(s)elected less any non-elective contribution allocable thereto will be withheld from my salary.  I elect to have(check coverage(s) desired:

                                                               
OVER THE COUNTER DRUGS NOW PERMITTED*

*Drugs and supplies for sickness or injury- no over the counter vitamins/dietary aids

Elect the amount you want Pre taxed for medical expenses 
 ($350 minimum, maximum based on individual employer's limit )       
Annual Election =   $

Elect the amount for Dependent Child/Adult Care  
($350 minimum- maximum $2,500 married filing single/$5,000 married)
Annual Election =  $

  (Please check with your accountant to make sure this is the best deduction for your situation)

I hereby elect the above flexible compensation items to be deducted from my paycheck. I certify that any dependent child care expenses do not exceed the lower of my or my spouse's income,  I also understand these elections are irrevocable except for a change in my family or employment situation, and cannot be deducted off of my income taxes. Reduced amount of taxable compensation not used to pay for eligible benefits during the year will be forfeited. Compensation contributed into one flex account cannot be transferred and used for expenses in any other account.

Please provide your electronic signature before we process your request. When you check the box, you agree the information you provide is accurate and complete to the best of your knowledge. Any attempts to commit fraud against the Myles Financial Service or it affiliate, may be subject to administrative penalties and/or criminal prosecution. Checking the box creates an electronic signature. An electronic signature is similar to your handwritten signature. Through the use of an electronic signature, you agree that the information you provide is accurate and complete to the best of your knowledge.

EMPLOYEE SIGNATURE                        Date

Electric Signature

WAIVER OF PRE TAX BENEFITS :

I elect to waive all pre tax benefits under the Flexible Benefits Plan offered by my employer, but understand that I may elect similar coverage(s) on an after tax basis. Except for a Change of Family Status, I understand that I cannot elect pre-tax

benefits until the next anniversary date, and any after tax coverage(s) shall be outside the Plan.

EMPLOYEE SIGNATURE                        Date:

PLEASE SUBMIT VIA ELECTRONIC SUBMISSION, RETURN TO YOUR PAYROLL OFFICE OR MAIL TO:

  Myles Financial Services, P.O Box 294, Florida New York 10921

845-651-3070   Fax 845-651-2170