State Of Indiana Employee'S Withholding Exemption And County Status Certificate
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1Health/Dependent Care Flexible Spending Account Enrollment Form
This form is designed to be completed by using your
computer and tabbing through the designated fields. If
Social Security Number
completing a printed copy by hand, please use black or
blue ink, print clearly and only in the spaces provided.
First Name
M.I.
Last Name
Date of Birth
MM
DD
YYYY
Address
City
State
Zip Code
Day Phone
Email
Need help deciding how much to elect or how much you will save using a Flexible Spending Account?
VISIT OUR WEBSITE at
I have reviewed the terms of my employer’s Plan and I understand that I may elect coverage under either or both of the accounts below,
subject to the terms of the Plan, for the Plan Year
.
NUMBER OF PAY PERIODS
DEPENDENT CARE
CONTRIBUTION PER PAY PERIOD
YOUR ANNUAL ELECTION AMOUNT
REMAINING IN PLAN YEAR
$
X
=
FLEXIBLE SPENDING
,
.
,
.
ACCOUNT
CANNOT EXCEED $5,000 PER HOUSEHOLD
NUMBER OF PAY PERIODS
HEALTH CARE
CONTRIBUTION PER PAY PERIOD
REMAINING IN PLAN YEAR
YOUR ANNUAL ELECTION AMOUNT
$
X
=
FLEXIBLE SPENDING
,
.
,
.
ACCOUNT
Please select your enrollment option below, then sign and date your form and submit to your benefit services department:
I elect to participate in my employer’s Flexible Spending Account Plan and agree to be bound by the terms of my
employer’s plan. I understand that the contribution(s) I have elected will be made with pre-tax salary reductions and that
such reductions reduce my compensation for Social Security benefit purposes. I understand that this agreement is only
for eligible services and treatment provided during the Plan Year and that said services must be provided before the
submission of claims for reimbursement. I also understand that I am making a binding election for the entire Plan Year
unless I have a qualified change of status as defined by my employer’s plan. Any salary deductions that have not been
used for expenses incurred in the Current Plan Year noted above will be forfeited.
If the Plan Administrator determines that an expense I submitted for reimbursement was not a qualified expense under
the Plan Documents, I shall immediately reimburse the Plan for the entire amount of the unqualified expense. If I fail to
timely reimburse the Plan, I understand that amounts may be withheld from wages or from otherwise valid expenses
under the Plan in order to reimburse the unqualified expense.
I decline enrollment in my employer’s Flexible Spending Account Plan.
Employee Signature
Date
Employer Section:
ADP FSA Client ID
Employee ADP Company Code
Effective Date of Employee Election
v20091101
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Parent category: Business