Lump Sum Payment Application Form
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1FSA
Lump sum payment application
Health
Please read carefully!
Flexible Spending
Account
Clear form
Employee name
First
Last
M I
Employee SSN:
Campus phone
Home phone
Payroll type
Reason for lump sum payment
Termination
Monthly
Academic
Retirement
Hourly
Ineligible for benefits
Leave
Salaried
Other
Date above reason will occur:
Current amount of health FSA contribution per payroll check $____________
Date of last regular payroll check _____________________
Indicate amount of lump sum contribution $________________
Lump sum amount extends health FSA enrollment through the month of ___________
month, year
Please consider the following lump sum criteria as you determine your final health FSA
contribution:
• The lump sum amount is limited to the total number and dollar amount of contributions remaining in the current
calendar year.
• The lump sum amount selected must be an increment of your current total monthly contribution. Health FSA
reimbursement for medical services rendered after your last paycheck is limited by the additional number of
months you extend your health FSA contribution through the lump sum payment.
• The gross amount of your last payroll check must be adequate to support the lump sum amount selected.
• The lump sum amount is deducted from the last regular paycheck before federal, state, and FICA taxes are
applied.
• The lump sum payment cannot be deducted from payroll checks for accrued annual leave.
• The lump sum payment method must be selected before the payroll deadline for your last regular
check. Please contact Employee Benefits for assistance.
• For Benefits Department Use Only •
Amount of override ________________
Signature of applicant
Date to begin
Override entered & date___________
Adjusted Med-max amount ___________
Date signed
By_______________________________
Revised 2/13/09
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Parent category: Legal