Fillable Flexible Spending Account Enrollment Form - Ameriflex printable pdf download

Flexible Spending Account Enrollment Form

Company Name:

Location:

Employee Name:

SSN:

Employee Email Address:

Home Address:

City:

State:

Zip:

Telephone:

Plan Year

through

Date of Birth:

Date of Hire:

Effective Date:

The company and I hereby agree that my cash compensation will be redirected by the amounts set forth below for each pay period during the plan

year (or during such portion of the year as remains after the date of this agreement). I understand that if I do not return this form to my employer by

my effective date, it shall constitute my election to waive participation in all flexible spending programs under my employer’s Flexible Benefits Plan

and therefore cause me to pay non-reimbursable medical, dependent care, and/or commuter expenses (if any) with after tax dollars.

EMPLOYEE’S FLEXIBLE BENEFIT PER DAY DEDUCTION/ALLOCATION

Medical

FSA

MEDICAL FLEXIBLE SPENDING ACCOUNT

Full

•

Full Flexible Spending Account

Per pay contribution: $

Date of first payroll:

Maximum ANNUAL Contribution

Annual contribution: $

Number of remaining pays:

H IDE

•

Limited Purpose Flexible Spending

Per pay contribution: $

Date of first payroll:

R EVEAL

Account

(i.e., vision and dental only)

Annual contribution: $

Number of remaining pays:

Maximum ANNUAL Contribution

Limited Purpose

•

DEPENDENT CARE SPENDING ACCOUNT

Per pay contribution: $

Date of first payroll:

H IDE

•

Maximum ANNUAL Contribution

Annual contribution: $

Number of remaining pays:

R EVEAL

COMMUTER REIMBURSEMENT ACCOUNT

P A R K I N G

Per pay contribution: $

Date of first payroll:

DCA

Maximum MONTHLY Contribution

Annual contribution: $

Number of remaining pays:

•

T R A N S I T

Per pay contribution: $

Date of first payroll:

H IDE

•

Annual contribution: $

Number of remaining pays:

Maximum MONTHLY Contribution

R EVEAL

I UNDERSTAND THAT:

CRA

(1) My accounts will not automatically renew. During each annual open enrollment period, I understand that I must complete a new enrollment form

•

indicating my account contributions for the new plan year.

(2) I cannot change or revoke this agreement at any time during the plan year unless I have a change in family status (including marriage, divorce,

H IDE

•

death of a spouse or child, birth or adoption of a child, termination or commencement of employment of a spouse, or such other events as the Plan

Administrator determines will permit a change or revocation of an election). Note: This does not apply to Commuter Reimbursement Accounts.

R EVEAL

(3) The Plan Administrator may reduce, cancel, or otherwise modify this agreement in the event he/she believes it is advisable in order to satisfy

certain provisions of the Internal Revenue Code.

This agreement is subject to the terms of the Company’s Flexible Benefits Plan, as amended from time to time, which shall be governed under applicable

FOR

laws, and revokes any prior agreement relating to such plan(s).

OFFICE

USE

By signing this form I agree to the terms and procedures listed herein.

ONLY

•

I was given the opportunity to participate in this Flexible Benefits Plan, and I have decided not to participate at this time.

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Employee Signature