Dependent Care Assistance Program (Dcap) & Washington Flex (Health Care Flexible Spending Account) 2013 Enrollment Form
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1Dependent Care Assistance Program (DCAP) &
Washington Flex (Health Care Flexible Spending Account)
2013 Enrollment Form
You must complete this form to start a tax-free account for either or both programs.
Name (Last, First, MI)
Social Security Number
Date of Birth
Street Address
City
State
ZIP Code
Daytime Phone
Home Phone
Agency or Higher-Education Institution Name
Employee I.D.
Enrollment Status
Annual Open Enrollment
New Hire
Special Open Enrollment
Career Seasonal/Contract Employee
Dependent Care Assistance Program (DCAP) Enrollment -- For child/elder daycare expenses
Benefits Office Use
State agency employees who are eligible for PEBB benefits can participate in DCAP. Qualified expenses include charges for the care and
# of Checks Remaining
well-being of a child or elder dependent while you work.
of
DO NOT include medical expenses for your dependents in the DCAP enrollment section. You will also need to enroll in the
Washington Flexible Spending Account if you want to claim medical expenses for your dependents.
Per Check Amount
Per Pay Period
Annual Election
Salary Reduction Amount
(Cannot exceed $5,000 annually, or $2,500 if married and filing
$
$
separate income tax returns)
Washington Flex Flexible Spending Account (FSA) Enrollment
Benefits Office Use
For health care expenses for you and your qualified tax dependents
State agency employees who are eligible for PEBB benefits can participate in the Health Care Flexible Spending account. Qualified
# of Checks Remaining
expenses include medical, dental, vision, and hearing expenses for you, your spouse, your qualified tax dependents and your adult children
through December 31 of the year the child turns age 26. Include only your expenses after reimbursement from insurance plans in this
of
election.
Salary Reduction Amount
Per Pay Period
Annual Election
Per Check Amount
(Minimum of $240, maximum of $2,500)
$
$
How do you prefer ASIFlex to reimburse you for your claims?
(select either Direct Deposit or Check)
Direct Deposit: If you choose to receive reimbursement by direct deposit, select one of these two options:
Please use same account information that is already being used for FSA and/or DCAP reimbursements by ASIFlex; OR
Please use account information below to set up direct deposit (attach a voided check or copy of a check to this form)
Name of bank ___________________
9-digit bank routing number ________________ Account number
This is a
checking account or
savings account
If you have your reimbursements deposited into your checking or savings account, how do you prefer ASIFlex to notify you of the deposit?
Notify me by e-mail. My e-mail address is_____________________________
OR
Mail the notice to my home address.
Check: If you choose to receive reimbursement by check, select this box.
Mail a check to my home address.
I understand:
I am requesting tax-free paycheck deductions based on the number of paychecks I expect to receive in 2013. If enrolling during the PEBB open
enrollment, these deductions will start with my first paycheck in 2013. If enrolling in 2013, these deductions will start no earlier than with the first
paycheck of the month after this form is submitted and approved by ASIFlex, through December 31, 2013. If enrolling in 2013, coverage is effective
no earlier than the first of the month after the submission of this form.
The DCAP and FSA benefits, and my rights and obligations under this plan, are specified in the DCAP Enrollment Guide and the Washington Flex
Enrollment Guide found on the ASIFlex website, and Washington Administrative Code found at
This form cancels any prior elections I have made under this plan, and cannot be changed except as stated in the DCAP Program Summary and the
Washington Flex Enrollment Guide found on the ASIFlex website, and Washington Administrative Code found at
Elections during the PEBB open enrollment are effective January 1, 2013 and are collected equally from each paycheck I will receive throughout 2013,
or during my contracted period of employment with the State of Washington.
Employee signature ___________________________
_____
____
Date ____________________
Return this form to your benefits office for processing.
Questions? Call ASIFlex toll-free at 1-800-659-3035 (Toll-free TTY 1-866-908-6043) or send an e-mail to
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