STATE OF FLORIDA FLEXIBLE BENEFITS PLAN

PRETAX PREMIUM WAIVER

Please type or print:	I am paid Biweekly Monthly

Last Name	First	MI	Social Security
Address	City	State	Zip Code
Home Phone	SunCom Number	Name of Department/Agency

I UNDERSTAND THE PRETAX PREMIUM PLAN AND CHOOSE NOT TO PARTICIPATE. I UNDERSTAND THAT I WILL NOT HAVE ANOTHER OPPORTUNITY TO PARTICIPATE UNTIL THE NEXT OPEN ENROLLMENT PERIOD.

SIGN HERE	DATE

FB-1

STATE OF FLORIDA FLEXIBLE BENEFITS PLAN

OSAS

2001-08-08

J0JEM

FDLES