Sample Flexible Spending Account FSA Administration

Sample_Documents

DISCLAIMER: This is a sample template provided for informational purposes only. It does not constitute legal, tax, or financial advice. Organizations should consult their own legal and tax advisors and tailor this document to reflect their specific business needs, geographies, and applicable laws.

Document Header

Document Title	Flexible Spending Account (FSA) Administration
Company	<Company Name>
Document Type	Flexible Spending Account (FSA) Administration
Category	Benefits & Wellness
Version	<Version Number>
Effective Date	<Date>
Last Updated	<Date>
Next Review Date	<Date> (review cycle: <Annual/Semi-Annual>)
Document Owner	Total Rewards <Owner Name/Title>
Contributors	Payroll, Finance, Legal/Compliance, HR Operations, <Vendor Name>
Approvers	<Chief People Officer>, <Head of Total Rewards>, <Legal Counsel>
Geographic Scope	<Country> and applicable jurisdictions where FSAs are offered

Purpose and Objectives

Define how <Company Name> designs, administers, funds, and governs Flexible Spending Accounts (FSAs) in compliance with applicable laws and plan documents.
Provide a standard operating framework for Total Rewards, Payroll, HR Operations, and vendor partners to deliver a compliant, efficient, and employee-friendly program.
Clarify roles, processes, controls, timelines, and decision rights for FSA administration.
Enable consistent, accurate, and timely employee communications and reimbursements.

Scope and Applicability

In Scope

Health Care Flexible Spending Account (general-purpose) for eligible medical, prescription drug, dental, and vision expenses.
Limited Purpose Health Care FSA (for HSA-compatible plans) restricted to eligible dental and vision expenses and, if applicable, post-deductible medical expenses.
Dependent Care Flexible Spending Account under applicable law for work-related dependent care expenses.
U.S. and other jurisdictions where FSAs are permitted by law, as designated by <Company Name>.
Processes spanning eligibility, enrollment, payroll deductions, claims, substantiation, communications, vendor management, nondiscrimination testing, and reporting.

Out of Scope

Health Savings Accounts (HSAs), Commuter Benefits, and Health Reimbursement Arrangements (HRAs) unless explicitly referenced for coordination.
Non-U.S. benefits where FSAs are not recognized or where local equivalents follow distinct rules.
Individual income tax advice.

Applicability

Applies to all eligible employees of <Company Name> in <Country> who meet plan eligibility requirements.
Applies to all internal departments and external vendors performing FSA-related services on behalf of <Company Name>.

Governance and Plan Documents

FSAs are governed by the formal Plan Document and Summary Plan Description (SPD) maintained by <Company Name> for the plan year beginning <Date>.
The Health Care FSA is an ERISA-covered group health plan and is subject to HIPAA privacy and security rules. The Dependent Care FSA is not an ERISA plan but remains subject to applicable tax and employment laws.
A wrap plan document may incorporate the FSA as a component of the <Company Name> Welfare Benefits Plan (Plan Number <Number>).
Legal basis includes Internal Revenue Code Sections 125 and 129 and applicable regulations. Limits and guidance may be updated annually by relevant authorities.
This administrative document complements, but does not replace, the Plan Document and SPD. In case of conflict, the Plan Document and SPD control.

Plan Overview

FSA Type	Primary Purpose	Eligible Expenses	Annual Limit	Availability Timing	Special Notes
Health Care FSA (General-Purpose)	Pre-tax reimbursement of qualified out-of-pocket medical, dental, and vision expenses for employee, spouse, and eligible dependents as defined by plan	Deductibles, copays, coinsurance, eligible OTC items, dental and vision care as permitted by law	Up to IRS limit each plan year: <Amount> (subject to annual IRS updates)	Uniform coverage: full annual election available on first day of plan year	Subject to HIPAA; COBRA continuation may apply in some terminations
Limited Purpose Health Care FSA (HSA-Compatible)	Pre-tax reimbursement restricted to dental and vision expenses and, if applicable, post-deductible medical expenses	Cleanings, orthodontia, glasses/contacts, vision exams; post-deductible expenses if plan permits	Up to IRS limit each plan year: <Amount>	Uniform coverage on first day of plan year	Designed for employees enrolled in HSA-eligible high deductible health plans
Dependent Care FSA (DCFSA)	Pre-tax reimbursement of eligible work-related dependent care expenses	Daycare, preschool (above custodial care age rules), before/after-school care, day camps, elder care while employee works	Up to statutory limit: <Amount> per household per year, subject to filing status restrictions	Not uniform coverage; only amounts contributed are available for reimbursement	Not subject to HIPAA; different nondiscrimination rules apply

Key Design Elections

Plan Year: <Start Date> through <End Date>.
Carryover or Grace Period for Health Care FSA (choose one):
- Carryover: up to <Amount> of unused funds may carry into the next plan year.
- Grace Period: up to <Months> months after plan year-end to incur expenses.
Run-Out Period: <Days> days after plan year end (or after grace period ends) to submit claims incurred during the plan year (and grace period, if applicable).
Claims Substantiation: all claims require IRS-compliant documentation; debit card transactions must be auto- or manually substantiated.
Domestic Partner Coverage: reimbursement eligibility follows tax-dependent rules; non-tax dependents may be ineligible or taxable. See Payroll and Legal guidance.

Eligibility and Participation

Employee Eligibility

Regular employees scheduled to work at least <Hours> hours per week are eligible as of <Eligibility Waiting Period> from date of hire or within the annual open enrollment period.
Interns, temporary workers, and contractors are not eligible unless required by law or specified in the Plan Document.
Dependent eligibility follows IRS definitions for tax dependents. For Health Care FSA, eligible dependents include spouse and tax dependents as defined by law. For Dependent Care FSA, dependents must meet qualifying child or qualifying person criteria.

Enrollment Windows

New Hire: within <Days> days of eligibility.
Open Enrollment: annually during <Month(s)> for the upcoming plan year.
Qualified Life Events (QLEs): mid-year changes allowed only when consistent with certain events.

Effective Dates of Coverage

Health Care FSA and Limited Purpose FSA: coverage effective <Date> or first of the month following eligibility per plan design; full annual election amount available at coverage effective date.
Dependent Care FSA: election effective <Date> or first of the month following eligibility; only contributed amounts are available for reimbursement as payroll deductions accrue.

Elections and Contribution Limits

Employees elect an annual contribution in whole dollars, up to the applicable IRS maximum and any company-specific minimum.
Elections are taken pre-tax from each applicable paycheck across the plan year.
Example calculation:

Employee elects <Amount> for Health Care FSA.
Employee is paid <Pay Frequency> times per year.
Per-paycheck deduction equals annual election divided by pay periods: <Amount> per paycheck.

Contribution limits:
- Health Care FSA: capped at IRS limit for the plan year, e.g., <Amount>; employer may set a lower plan maximum of <Amount>.
- Limited Purpose FSA: same limit as the Health Care FSA, per IRS; may be reduced by plan.
- Dependent Care FSA: capped at <Amount> per calendar year per household, subject to filing status limits and earned income rules.

Tax savings considerations:
- Combined federal, state, and FICA savings may range from approximately <Percentage>% to <Percentage>% depending on individual tax situation.
- Dependent Care FSA coordination with the child and dependent care tax credit should be evaluated by employees with their tax advisors.

Mid-Year Election Changes

FSAs generally follow the irrevocable election rule under Section 125: elections may not be changed mid-year unless a permitted change-in-status event occurs and the change is consistent with the event.
Typical qualifying events include:

Marriage, divorce, legal separation, or death of spouse or dependent
Birth, adoption, or placement for adoption
Change in employment status affecting eligibility for the employee, spouse, or dependent
Significant change in cost or coverage for dependent care arrangements
Dependent’s status change (e.g., aging out for dependent care)
HIPAA special enrollment events for health coverage that may permit related FSA changes
Judgment, decree, or order relating to dependent coverage or care

Documentation requirements apply for all mid-year changes. Changes are effective prospectively from the event date or documentation date per plan rules.

Plan Design and Administrative Rules

Carryover vs. Grace Period (Health Care FSA)

Employers may adopt either a carryover or a grace period, not both.
Best practice: adopt a carryover up to the IRS limit of <Amount> to enhance predictability and reduce forfeitures for employees while limiting administrative complexity.
If a grace period is used, claims incurred during the <Months>-month grace period may be reimbursed from remaining prior-year balances; run-out will follow the grace period.

Uniform Coverage Rule (Health Care FSA)

The full annual election is available at the start of coverage.
If employment terminates mid-year, payroll deductions cease; claims incurred while covered remain eligible, and overspent accounts are not recouped from employees except via remaining payroll deductions.

Dependent Care FSA Availability

Reimbursements are limited to the amount contributed and available in the account at the time of claim adjudication.
Eligibility must meet work-related care criteria and the provider may not be a tax-dependent of the employee.

Run-Out and Forfeitures

All claims must be submitted by the end of the run-out period.
Unused funds after carryover or grace period expiry are forfeited per the use-it-or-lose-it rule.

Substantiation and Debit Card Usage

Every transaction must be substantiated with IRS-compliant documentation unless it qualifies for established auto-substantiation rules (e.g., copay match, real-time inventory systems).
Acceptable documentation includes the provider name, date of service, type of service, and amount paid. Credit card slips alone are insufficient.

Coordination with HSAs

Employees enrolled in HSA-eligible high deductible health plans should only enroll in a Limited Purpose FSA to preserve HSA eligibility.
A post-deductible FSA option may become general-purpose once the statutory deductible is satisfied if the plan is designed accordingly and the employee attests timely.

Eligible and Ineligible Expenses

Health Care FSA (General-Purpose)

Eligible: plan-covered deductibles, coinsurance, copays, prescription drugs, insulin, dental services, orthodontia, vision exams, glasses and contacts, and eligible OTC medications per law.
Ineligible: cosmetic procedures, premiums, non-medically necessary items, expenses incurred before or after coverage, expenses already reimbursed elsewhere.

Limited Purpose Health Care FSA

Eligible: dental and vision expenses; if post-deductible allowed, eligible medical expenses incurred after the IRS minimum deductible is met.
Ineligible: general medical expenses prior to meeting deductible.

Dependent Care FSA

Eligible: work-related care for qualifying dependents, including daycare, before/after-school programs, day camps, elder day care.
Ineligible: overnight camps, educational tuition beyond custodial care, payments to a child under age <Age> who is your dependent, expenses not enabling the employee and spouse to work or seek work.

Claims and Reimbursements

Submission Methods

Employees may submit claims via <Vendor Name> web portal, mobile app, or by secure upload as specified by the vendor.
Debit card may be issued for Health Care FSA and Limited Purpose FSA. DCFSA generally reimburses after proof of expense.

Documentation Standards

Required elements: provider name, service date(s), description of service, patient name (for health claims), and amount paid.
Explanation of Benefits (EOB) from the health plan is preferred for medical claims.
Orthodontia may require a treatment contract showing total cost, treatment period, and payment schedule.

Adjudication and Payment Timelines

Standard SLA: adjudicate complete claims within <Business Days> business days.
Payment via direct deposit within <Business Days> business days after approval; paper checks only when direct deposit is unavailable.

Denials and Appeals

Claim denial notices include reason, documentation needed, and appeal instructions.
Appeal window: <Days> days from denial; final determination within <Days> days of receipt of complete appeal.
For Health Care FSA, ERISA-compliant appeals process applies, including the right to a second-level review when applicable.

Leaves of Absence, Terminations, and COBRA

Health Care FSA during unpaid leave:
- Employees may continue coverage by making after-tax direct payments or allow coverage to lapse and reinstate upon return per plan rules.
- If coverage continues, uniform coverage remains in effect.
Dependent Care FSA during leave:
- Employee may pause contributions; reimbursements require incurred expenses while still eligible and may be limited by account balance.
Termination of employment:
- Health Care FSA COBRA: if account is underspent at termination, COBRA continuation may apply through the end of the plan year at a rate of <Amount> per month plus up to <Percentage>% administrative fee.
- DCFSA: no COBRA; claims must be incurred while employed and eligible.
Final payroll deductions are taken from the final paycheck if timing allows.

Nondiscrimination Testing (NDT)

Annual and mid-year testing to ensure benefits do not favor highly compensated or key employees.
Section 125 testing for cafeteria plans:
- Eligibility test
- Benefits and contributions test
- Key employee concentration test
Section 129 testing for Dependent Care FSA:
- More-than-5% owners limitation
- 55% average benefits test
- Eligibility and utilization review
Data sources:
- HRIS census as of testing date
- Contribution and participation data by plan and by employee group
Remediation:
- If testing indicates failure, adjust future election amounts, suspend elections for certain groups, or recharacterize contributions as taxable to affected participants. Legal review is required before action.

Payroll and Accounting

Payroll Deduction Setup

Deduction codes:
- Health Care FSA pre-tax: <Code>
- Limited Purpose FSA pre-tax: <Code>
- Dependent Care FSA pre-tax: <Code>
Timing: per-pay-period deductions applied evenly across remaining pay periods of the plan year.
Changes due to QLEs or new hires are prorated prospectively.

Tax Treatment

Contributions are pre-tax for federal income tax, most state income tax (where applicable), and FICA up to statutory limits.
Reimbursements are non-taxable if used for qualified expenses incurred during the coverage period.
Domestic partner and non-tax dependent expenses are not eligible for tax-free reimbursement; consult Payroll and Legal.

General Ledger and Funding

FSA bank account held by <Vendor Name> or <Company Name> per contract.
Health Care FSA prefunding liability: employer recognizes full-year risk of uniform coverage; monitor adverse selection and forfeitures.
Funding cadence: <Weekly/Biweekly/Monthly> funding of approved claims plus card settlements; reconciliation performed by Finance.
GL mapping:
- Employee contributions: credit liability accounts <Account Numbers>
- Claims expense and liability reductions: debit/credit <Account Numbers>

Vendor Management and Service Levels

Vendor selection criteria: compliance record, substantiation capabilities, card technology, integration with HRIS/payroll, fees, employee experience, security posture, and reporting.
Minimum service levels:
- Average speed to adjudicate: <Business Days>
- Call center service level: <Percentage>% of calls answered within <Seconds> seconds
- First-contact resolution: <Percentage>%
- System uptime: <Percentage>%
Data integrations:
- Eligibility file: <Frequency> with effective dates and coverage types
- Payroll contributions file: <Frequency> with per-pay deductions
- Claims and payment files: <Frequency> for reconciliation
Performance reviews: quarterly business reviews with metrics, issues log, and action items.

Data Privacy, Security, and HIPAA

Health Care FSA is a covered entity for HIPAA privacy and security. Business Associate Agreement required with <Vendor Name>.
Minimum necessary standard applies to all PHI transfers.
Access controls:
- Role-based access for HR and vendor teams
- Audit logs retained for <Years> years
Incident response:
- Report suspected breaches within <Hours> to Privacy Officer and Legal
- Follow breach notification rules under applicable law
Dependent Care FSA data is not PHI but remains confidential personnel data.

Risk Management and Internal Controls

Key controls:
- Dual-review of eligibility and payroll files
- Three-way monthly reconciliation: vendor reports, payroll deductions, GL postings
- Sample audit of claims documentation by vendor quality team
- Approval workflow for plan design changes and communications
Fraud prevention:
- Card transaction monitoring and merchant category code controls
- Random documentation audits even for auto-substantiated card swipes
Business continuity:
- Vendor must maintain disaster recovery with recovery time objective of <Hours> and recovery point objective of <Hours>.

Implementation Guidelines

Project Phases

Design: finalize plan features (carryover or grace, run-out, card), limits, eligibility rules, and plan year dates
Vendor Setup: establish plan IDs, bank/funding, card parameters, auto-substantiation rules
Systems Integration: configure HRIS eligibility, payroll deductions, file feeds, and GL mappings
Documentation: update Plan Document, SPD, employee communications, and intranet content
Testing: validate file exchanges, card transactions, claims workflow, and payroll deductions end-to-end
Training: equip HR support, payroll operations, and vendor care teams with process guides and FAQs
Launch: open enrollment, enrollment support, and go-live monitoring
Stabilization: review first 60 days, address defects, confirm reconciliations, and collect feedback

Timeline Example

Project kickoff: <Date>
Configuration complete: <Date>
End-to-end testing: <Date> to <Date>
Open enrollment window: <Date> to <Date>
File and payroll cutover: <Date>
Effective date: <Date>

Metrics and Reporting

Participation rate by FSA type: target <Percentage>% of eligible population
Average annual election amount by plan
Forfeiture rate: target less than <Percentage>%
Claim turnaround time vs. SLA
Debit card substantiation rate and denial rate
Nondiscrimination testing pass/fail indicators
Employee satisfaction scores from post-enrollment surveys

Annual Calendar

Month	Activity
<Month>	Confirm IRS limits, propose plan design updates, begin vendor SOW review
<Month>	Draft and route Plan Document and SPD updates for approval
<Month>	Configure systems, prepare communications, and schedule open enrollment
<Month>	Open enrollment and employee education sessions
<Month>	Finalize payroll deductions, push initial eligibility files, and issue debit cards
<Month>	Mid-year NDT checkpoint; remediation if needed
<Month>	Year-end reminders on run-out and carryover; finalize vendor QBR

Roles and Responsibilities

Total Rewards

Own plan design, vendor oversight, and regulatory compliance in collaboration with Legal.
Approve employee communications and manage open enrollment content.
Coordinate nondiscrimination testing and remediation strategies.

Payroll

Configure deduction codes, calendars, and per-pay calculations.
Reconcile contributions and manage corrections for missed deductions.
Support taxation rules and year-end reporting as applicable.

HR Operations

Manage employee inquiries and escalate complex cases to vendor or Total Rewards.
Process QLE documentation and ensure timely effective dates.
Maintain internal knowledge base and process guides.

Finance and Accounting

Oversee funding schedules, GL postings, and reconciliations.
Monitor prefunding exposure for Health Care FSA and maintain reserves.
Participate in vendor audits and financial reviews.

Legal and Compliance

Review plan documents and communications.
Ensure HIPAA compliance and oversee BAAs.
Advise on nondiscrimination testing and corrective actions.

Vendor Partner (<Vendor Name>)

Provide claims administration, customer support, card services, and reporting.
Maintain secure systems and meet SLAs.
Support integrations and data exchanges with <Company Name> systems.

Employees and Managers

Employees elect contributions responsibly, retain documentation, and submit claims timely.
Managers support employee awareness by reinforcing key dates and resources.

Review and Approval Process

Total Rewards drafts plan design and administrative updates and circulates to Payroll, Finance, HR Ops, and Legal for input
Legal reviews for compliance with Section 125 and Section 129, ERISA, HIPAA (as applicable), and local laws
Final draft routed to approvers listed in Document Header
Upon approval, Total Rewards updates the Plan Document, SPD, and intranet content and communicates effective dates
Post-implementation review conducted within <Days> days of effective date, with any corrective updates routed for rapid approval

Version History

Version	Effective Date	Summary of Changes	Author	Approver
<1.0>	<Date>	Initial release	<Name>	<Name>
<1.1>	<Date>	Updated limits and carryover amount; added vendor SLA metrics	<Name>	<Name>

Glossary

Annual Election: the total amount an employee chooses to contribute for the plan year.
Carryover: a plan design that allows a limited amount of unused Health Care FSA funds to carry into the next plan year.
COBRA: a law allowing continuation of certain health benefits, potentially including underspent Health Care FSA coverage.
Dependent Care FSA (DCFSA): account for work-related dependent care expenses under Section 129.
Grace Period: additional time after plan year-end to incur expenses in lieu of carryover.
HIPAA: privacy and security rules applicable to Health Care FSAs as group health plans.
HSA-Compatible or Limited Purpose FSA: an FSA limited to dental and vision expenses designed to preserve HSA eligibility.
Nondiscrimination Testing (NDT): tests ensuring plans do not favor highly compensated or key employees.
Run-Out Period: period after the plan year to submit claims incurred during the plan year (and grace period, if applicable).
Uniform Coverage Rule: Health Care FSA rule making the full annual election available on day one of coverage.
Use-It-Or-Lose-It: forfeiture of unused FSA funds after applicable carryover or grace and run-out periods.

Communication to Employees and Managers

About Your Flexible Spending Accounts at <Company Name>

Welcome to your overview of Flexible Spending Accounts, or FSAs. These accounts let you set aside pre-tax dollars from your paycheck to pay for eligible expenses, which can lower your taxable income and help your budget go further. You choose how much to contribute for the year, and you can spend those funds on many everyday expenses.

There are two main types of FSAs available at <Company Name>.

Health Care FSA: Use this account for eligible out-of-pocket medical, prescription, dental, and vision expenses for you and your eligible family members. Examples include copays at the doctor, prescriptions, and eyeglasses. With this account, your full annual election is available on the first day of the plan year.

Dependent Care FSA: Use this account for work-related dependent care expenses, like daycare, after-school programs, day camps, or elder care. Only the money you have contributed so far is available to reimburse dependent care expenses.

If you are enrolled in an HSA-eligible health plan, you may be offered a Limited Purpose Health Care FSA instead of the general Health Care FSA. That version is designed for dental and vision expenses so you can keep contributing to your HSA.

Key Dates and How to Enroll

Plan Year: <Start Date> through <End Date>
Enrollment Windows:
- New hires: enroll within <Days> days of your eligibility date
- Open Enrollment: <Date Range>
- Mid-year changes: allowed only when a qualifying life event happens, like a birth or marriage, and the change is consistent with that event

Enroll through <HRIS/Benefits Portal Name>. You will choose an annual dollar amount for each account you want. Your contributions will be taken evenly from each paycheck before taxes.

Spending Your FSA and Getting Reimbursed

For the Health Care FSA, you may receive a debit card from <Vendor Name> to pay for eligible expenses at the point of sale. Keep your receipts even if you use the card. Sometimes the law requires us to verify what you bought, and you will need to provide documentation that shows the provider name, date of service, what service or product you received, and how much you paid. If you prefer, you can also pay out of pocket and then submit a claim through the <Vendor Name> portal or app for reimbursement by direct deposit.

For the Dependent Care FSA, pay your provider as usual and submit claims with proper documentation through the <Vendor Name> portal. You will be reimbursed up to the amount you have contributed so far.

Our goal is to process complete claims within <Business Days> business days. Be sure to submit your claims by the end of the run-out period, which ends <Days> days after the plan year (or grace period) ends.

How Much Should I Contribute?

Think about what you typically spend each year on eligible expenses. Here are examples to get you started.

Health Care FSA sample budget:
- Primary care and specialist copays: <Amount>
- Prescriptions and eligible OTC medications: <Amount>
- Dental cleanings or orthodontia payments: <Amount>
- Vision exam and new glasses: <Amount>

Dependent Care FSA sample budget:
- Daycare tuition: <Amount> per month x <Months> months
- After-school program: <Amount> per month x <Months> months
- Day camp during school breaks: <Amount>

Because FSAs are generally “use-it-or-lose-it,” choose an amount you are confident you will spend. If our plan includes a carryover of up to <Amount> for the Health Care FSA, that can provide a cushion for unexpected changes.

What Expenses Are Eligible?

Health Care FSA: many medical, dental, and vision expenses are covered, including copays and prescriptions. Some items, like cosmetic procedures, are not covered. When in doubt, check the <Vendor Name> eligible expense list.
Dependent Care FSA: work-related care for children under age <Age> or for eligible adult dependents may be covered. Overnight camps and school tuition are not covered.

Remember that rules are set by law, not by <Company Name>, so we must follow them consistently.

Life Events and Changes

Certain life events may allow you to change your FSA election mid-year. Examples include marriage or divorce, birth or adoption, a change in your or your spouse’s employment status that affects eligibility, or significant changes to your dependent care arrangements. Submit your request within <Days> days of the event through <HRIS/Benefits Portal Name> and upload required documentation.

Leaving <Company Name> or Taking Leave

If you leave <Company Name> or go on unpaid leave, your options depend on the account type and your situation. Health Care FSA coverage may be continued through COBRA in certain cases. Dependent Care FSA does not continue through COBRA. Specific details will be provided based on your circumstances.

Getting Help

Vendor Support: <Vendor Name> at <Phone Number> or <Website URL>
<Company Name> Benefits: <Benefits Email> or <Internal Site Link>
Claims and eligible expense lists: <Vendor Name> portal or app

This overview is for convenience only. The Plan Document and Summary Plan Description govern the program. If there is a conflict, those documents control. For personalized tax advice, please consult your tax advisor.

Document Information:

Document Type: Flexible Spending Account (FSA) Administration
Category: Benefits & Wellness
Generated: August 24, 2025
Status: Sample Template
Next Review: <Insert Review Date>

Usage Instructions:

Replace all text in angle brackets < > with your company-specific information
Review all sections for applicability to your organization
Customize content to reflect your company's policies and local regulations
Have legal and HR leadership review before implementation
Update document header with your company's version control information
At bottom of the document you find a short example on how the content could be communicated to end-users, for instance employees.

This sample document is provided for reference only and should be customized to meet your organization's specific needs and local legal requirements.