Flexible Spending Account Enrollment Form - Ameriflex Page 2
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2Flexible Spending Account Enrollment Form
page 2
ADDITIONAL CARDS
(only applicable if your employer has chosen this option)
If you wish to have an Ameriflex Convenience Card
®
issued for a spouse or dependent, please be sure your spouse
or dependent meets the IRS eligibility guidelines below:
(1) For federal tax purposes, a spouse includes all legally married same-sex or opposite-sex spouses, regardless of state residence.
(2) A “dependent” generally includes any relative of the participant for whom the participant provides over half of their support for the calendar
year. A relative includes children, parents, stepchildren, siblings, aunts, uncles, cousins, and in-laws of the participant. Relatives do not need to
reside with the participant in order to be dependents, nor do they need to be a certain age or infirmity; they need only to be persons for whom
the participant has provided over half of their support.
Spouse Name:
Address to issue card:
Telephone:
SSN:
Date of Birth:
®
All dependents must be age 18 or over in order to receive the Ameriflex Convenience Card
. If you previously added
a dependent onto your plan, they will automatically be linked each year. It is your responsibility to add and/or remove
dependents as needed. To add additional dependents or to remove dependents, please complete the section below.
Dependent Name:
Add
Remove
Address to issue card
:
(if differecnt from participant)
Telephone:
SSN:
Date of Birth:
Dependent Name:
Add
Remove
Address to issue card
:
(if differecnt from participant)
Telephone:
SSN:
Date of Birth:
®
Each Ameriflex Convenience Card
is issued for a term of three years. Remember that existing cardholders will not receive a new card (unless
the current card is scheduled to expire). Cards will simply be “reloaded” for the next plan year with your new election. Upon expiration, Ameriflex
®
will automatically issue new cards to participants who re-enroll in the new plan year. For new participants, your Ameriflex Convenience Card
will be sent to your home adress in a plain white envelope.
Employee Signature
Date
Ameriflex
Fax:
800.282.9818
Email:
Please fax or email this form to:
8 8 8 . 8 6 8 . F L E X ( 3 5 3 9 )
T O L L
F R E E :
FSAenroll_2015v.1
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