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0 An.I'K 628 6) <br />ELFC7'IQN LEE__QSINTY FJ,EXIIF_.FE JF.FI1' PLAN <br />Election to choose amonq two or more benefits relative to <br />Article IV of the Lee County Flexible Benefits Plan. <br />1. I elect to reduce my compensation by $i - <br />per month to be used by the County to provide me with a <br />taxable benefit or to purchase or provide me with a nontax- <br />able benefit. <br />2. I make the following irrevocable election for the period <br />covered by the Plan year. <br />To receive cash in the amount of $ per month <br />and $ per month applied to the purchase of health <br />care insurance under the Countv's Health Care Program. <br />3. This election shall be irrevocable and shall continue in <br />effect until July 1, 11085, or until such time as a new <br />election is permitted under Section 4.03 of the Lee County <br />Flexible Benefits Plan and an election is submitted to the <br />Plan Administrator. However, any changes in the status of my <br />family may permit me to change this election. <br />Signature <br />Date <br />NORTH CAROLINA, LEE COUNTY <br />Pres ted for registration oonntthe. day <br />of191E? at91~~~M. <br />recorded in Book_~ PageJ2t-= <br />Wanda K. Thomas, Register of Deeds <br />