Health/dependent Care Flexible Spending Account (Fsa) & Limited Purpose Fsa Enrollment Form printable pdf download

*EMPLOYER MUST FILL-IN*

Health/Dependent Care

Re-enrollment __ New __ Change __

Effective Date _________________

Flexible Spending Account (FSA)

1st Deduction Date _____________

& Limited Purpose FSA

Payroll Mode

W B S M Q

Enrollment Form

Division Code _________________

I. Personal Information

(Please print clearly and provide complete and accurate information.)

Your Employer ______________________________________________________ Employer ID # _______________________________

(EMPLOYER MUST FILL-IN)

____________________________

Member #

Your Name ____________________________________________________________

(This may be your SSN or employer assigned number)

(Last)

(First)

(MI)

Address________________________________________City ____________________________ State ______ Zip __________

________

Date of Birth ______

______

Hire Date ______

______

Check if this address is new within last year.

II. Election Information

(Please check the appropriate box to indicate if you wish to enroll, or do not wish to enroll, and sign below.)

Yes, I wish to participate in the Limited Purpose Flexible Spending Account plan and authorize payroll reduction from my salary on a pre-tax basis in the amount(s) indicated

below, and continuing until this election is amended or terminated or until the Plan Year ends. Employer-sponsored benefit coverage contributions are automatically reduced

from my compensation on a pre-tax basis.

Yes, I wish to participate in the Health/Dependent Care Flexible Spending Account plan and authorize payroll reduction from my salary on a pre-tax basis in the amount(s)

indicated below, and continuing until this election is amended or terminated or until the Plan Year ends. Employer-sponsored benefit coverage contributions are automatically

reduced from my compensation on a pre-tax basis.

I have been offered the opportunity to enroll in a Health/Dependent Care FSA and Limited Purpose FSA plan and do not wish to enroll at this time. However, my employer-

sponsored benefit coverage contributions are automatically reduced from my compensation on a pre-tax basis.

*All fields must be complete in order to enroll in the plan*

PER PAY PERIOD

NUMBER OF

PLAN YEAR

BENEFIT CHOICES

AMOUNT

PAY PERIODS

AMOUNT

Healthcare Reimbursement Account (FSA)

________

$________

____

$__________

____

(If you are enrolled in a Health Savings Account, you cannot enroll in a Healthcare

FSA)

Dependent Day Care Reimbursement Account (FSA)

________

$________

____

$__________

____

(If married, this amount is less than my spouse’s earned income)

Limited Purpose Flexible Spending Account (LPFSA)

________

$________

____

$__________

____

(Only available if you are enrolled in a Health Savings Account)

I understand that:

• If enrolled in an HSA, I may only participate in a Limited Purpose FSA. Elections to Limited Purpose FSA can only be changed or revoked during the Plan Year and if I have a

change in status as defined in the Plan or if I am no longer eligible to participate. The new election must be consistent with my change in status, must be applied for within 30

days of the change, and is subject to final approval by my employer.

• The Health/Dependent Care FSA election can only be changed or revoked during the Plan Year if I have a change in status as defined in the Plan or if I am no longer eligible to

participate. The new election must be consistent with my change in status, must be applied for within 30 days of the change, and is subject to final approval by my employer.

• This election will be automatically changed or cancelled, if necessary, to comply with provisions of the Internal Revenue Code or if required employer-sponsored benefit

contributions increase or decrease.

• The maximum exclusion under a Dependent Care Reimbursement Account for married individuals filing a joint return is $5,000 per calendar year. Married individuals filing

separately will get a lower exclusion ($2,500 per calendar year). IRS Form 2441 must be filed with my personal income tax return.

• Any amounts remaining in my Limited Purpose FSA at the end of the Plan Year will be forfeited

• Salary contributed into one reimbursement account cannot be transferred and used for expenses in any other account.

• A new Enrollment Form must be completed each Plan Year. If I do not complete and return an Enrollment Form during Open Enrollment, I forfeit the opportunity to participate

in the Benefit Choices outlined above.

• Social Security and Medicare taxes are not being withheld on the amount of my salary reduction under this election.

• The amount of salary reductions may not be claimed on my or my spouse’s income tax returns.

• I understand all Health/Dependent Care FSA and Limited Purpose FSA claims submitted for reimbursement are subject to substantiation requirements and I am required to, and

agree to, provide documentation as requested.

• If using the PayFlex Debit Card, I agree to use the card for eligible expenses only and retain all itemized receipts/statements. I agree to read and adhere to the cardholder

statement I receive with the card and I understand the card is subject to inactivation if I do not comply with the provisions or upon termination of employment.

• Any expenses I pay for with the PayFlex Debit Card or for which I claim reimbursement will not have been nor will I seek to have reimbursed elsewhere.

III. Pre-Authorization for Direct Deposit

(If you are already enrolled in direct deposit or do not wish to, ignore this section.)

I authorize PayFlex Systems USA, Inc. to initiate a credit and/or debit entry to my account for my PayFlex reimbursements.

This agreement is to remain in full effect until written notification is supplied by me to PayFlex terminating this agreement.

A “VOIDED” CHECK MUST ACCOMPANY DIRECT DEPOSIT APPLICATION

Employee Signature ________________________________________________ Date ____________________

Health/dependent Care Flexible Spending Account (Fsa) & Limited Purpose Fsa Enrollment Form

Related Articles

Related forms

Related Categories