Form Fsa001 - Election Form/compensation Reduction Agreement (Paychex) - 2012
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Client BIS ID _______________
Election Form/Compensation
Reduction Agreement
Flexible Spending Account
SECTION 1 - EMPLOYEE INFORMATION
Office/Client Number ________________________________
(print)
Company Name ____________________________________________________ Employee Telephone Number (
) _______ - __________
Employee Name ____________________________________________________ Social Security Number ______________________________
Address ________________________________________ City ______________________________ State _____
ZIP Code ____________
Email Address ________________________________________________________________________________________________________
SECTION 2 - ENROLLMENT OPTIONS
(select one)
Note: If Change in Status has occurred, changes in enrollment and
New Enrollment or Annual Enrollment Changes
supporting documentation must be submitted to the Employer
Date of Hire
/
/ _________
within 30 days of the event.
Notes: New enrollments will be effective on the first payroll of the
Dependent care cost provider changes
month following the date the eligibility requirements are met.
Dependent satisfies or ceases to satisfy dependent eligibility
requirements
Annual enrollment changes will be effective on the first payroll
Birth/Death of spouse or dependent, adoption or placement for
following January 1.
adoption
Debit Card
Spouse's employment commenced/terminated
Dependent’s name (if applicable) _______________________
Status change from full-time to part-time or vice versa by employee
or spouse*
Notes: Participants may only request a debit card if their employer has
Eligibility or Ineligibility of Medicare/Medicaid
selected the service. If the debit card option is selected and the
Change from salaried to hourly or vice versa*
Plan does not offer the debit card service, no card will be
Marriage/Divorce/Legal Separation
requested. Refer to your Summary Plan Description for plan
Unpaid leave of absence by employee or spouse
features.
Return from unpaid leave of absence by employee or spouse
Termination of employment (your enrollment will be terminated)
Participants may choose only one dependent.
Change In Status
*
These changes are allowable only if eligibility is affected.
Date of Event _________ / ________ / _________
SECTION 3 - ENROLLMENT ELECTION
Annual Dependent Care Election
_____________
$
(DCA)
Annual Medical/Dental/Vision Election $ ________________ (UME)
Maximum $5,000.00
Cannot Exceed Company Maximum
DCA is issued for custodial care of a dependent, not for medical expenses of a dependent.
Discontinue my Enrollment in Medical/Dental/Vision Care
Discontinue my Enrollment in Dependent Care
Notes: To discontinue enrollment, a change in status reason must be selected.
To calculate your per-pay-period deduction, divide your annual amount by the number of pay periods remaining in the plan year.
SECTION 4 - AUTHORIZATION
I hereby elect to participate in the Flexible Spending Account for the Plan Year
/
/
. Any previous election and compensation reduction
agreement relating to the same benefits is hereby revoked. I cannot change or revoke this election at any date prior to the next plan year unless I experience a
change in status (also referred to as a qualifying event). If, during my next enrollment period, I do not complete and return a new election form during my
enrollment period, I will be treated as having elected to continue my employee election as set forth in this election form for the next plan year. As a participant, I
understand that all guidelines regarding enrollment are set forth in the Summary Plan Description.
Reduction of Pay
I understand that my pay will be reduced each pay period by the amount of
I agree to notify my Employer if I believe that any expense for which I
my required contribution for the benefit option(s) I have elected until this
have received reimbursement is not a qualifying expense. I also agree
agreement is amended or terminated. The reduction in my pay under this
to indemnify and reimburse the Employer for any liability Employer may
agreement will be in addition to any reductions under other agreements or
incur for failure to withhold income or FICA tax from any reimbursement
benefit plans.
I receive of a non-qualifying expense.
I understand that my pay reduction will be automatically adjusted if my
I understand that I will forfeit any balances I have at the end of the year
required contributions change while this agreement is in effect and that the
for which I have no eligible expenses to submit.
plan administrator may change the amount of my pay reduction or otherwise
FSA with an HSA
modify this agreement if it is required to satisfy provisions of the Internal
If I have a Flexible Spending Account in conjunction with a Health
Revenue Code.
Savings Account (HSA), I may only submit medical expenses under the
Reimbursements
Unreimbursed Medical portion of my Flexible Spending Account for
I understand that my Employer will hold my contributions for payment of
dental, vision, and preventative care. My HSA may be used to pay for
eligible expenses incurred within the Plan Year and that reimbursement will
any remaining HSA-qualified medical expenses.
be available only for qualifying expenses.
Employee Signature ______________________________________________________
Date
/
/
ENROLL or REVISE ENROLLMENT at or on the FSA Information Line by dialing 877-244-1771, Flexible
Spending option. MAIL or FAX to Paychex, Section 125 Department, 1175 John Street, West Henrietta, NY 14586 • Fax: 585-389-7349
FSA001 8/12
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