Enrollment Form - Fsa Dca Lpf printable pdf download

Flexible Spending Account Enrollment Form

Employer:

Plan Year:

20 _ _

This Enrollment Form is being used to:

(Check one)

Initially enroll or annually re-enroll in the Cafeteria Plan

Waive participation in the Cafeteria Plan

Participant Information

Required fields

Employee Name*

SSN*

Last

First

M.I.

Address

Street

City

State

Zip

E-mail Address*

DOB*

mm/dd/yyyy

Enrollment Information

I elect to reduce my compensation for each pay period during the plan year and redirect such dollars into the Cafeteria

Plan as set forth below.

Insurance Premiums:

All eligible premiums will be automatically deducted Pre-Tax on my behalf UNLESS I check this box indicating that I

wish to have these premiums deducted Post-Tax.

Contributions Per

Number of Pay

Annual Election

Pay Period

Periods

Health Care FSA

Dependent Care FSA

Limited Purpose FSA

(Dental & Vision)

Debit Card

I understand that I will automatically receive a debit card with my enrollment in the FSA plan and I would like to order a card for

my spouse or dependent.

_________________________________________________________________________________________________________

Spouse or Dependent Name

SSN

Birth Date

Signature and Authorization

I understand that an election is made before a year begins and cannot be changed until the next year. No changes are allowed during the year unless

there is a change of status. I agree to notify the Company if I have reason to believe that any expense for which I have obtained reimbursement is not

a qualifying expense. I also agree to indemnify and reimburse the Company on demand, for any liability it may incur for failure to withhold federal,

state, or local income tax or Social Security tax on any reimbursement I receive of a non-qualifying expense, up to the amount of additional tax actually

owed by me. I agree to follow the terms and conditions set forth in the Summary Plan Description. The Plan Administrator may reduce my compensa-

tion reduction or otherwise modify this agreement in the event it is believed to be advisable in order to satisfy provisions of the Internal Revenue Code.

My Social Security benefits may be slightly reduced as a result of my election. This agreement will automatically terminate if the Plan is terminated or

discontinued, or if I cease to receive compensation from the Company. If my employment is terminated I agree to contact Rocky Mountain Reserve

regarding my account.

Employee Signature

Date