Enrollment/change Form - Flexible Spending Accounts (Fsa) Program - 2017
Download a blank fillable Enrollment/change Form - Flexible Spending Accounts (Fsa) Program - 2017 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Enrollment/change Form - Flexible Spending Accounts (Fsa) Program - 2017 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4PAGE 1 of 4
The Health Care Flexible Spending Account (HCFSA) Program and the Dependent Care Assistance Program (DeCAP)
are divisions of the Office of Labor Relations’ Tax-Favored Benefits Program.
Reset Fields
PLAN YEAR 2017 ENROLLMENT/CHANGE FORM
FLEXIBLE SPENDING ACCOUNTS (FSA) PROGRAM
Print Form
Bowling Green Station, P.O. Box 707, New York, NY 10274
(212) 306-7760
TTY: (212) 306-7629
nyc.gov/fsa
Please review the FSA Program Brochure and Pages 3 and 4 of this form before completing.
PROGRAM
or
or
(
):
q HCFSA
q DeCAP
q HCFSA and DeCAP
check one
ENROLLMENT PERIOD:
q Open Enrollment Period (Sept. 19, 2016 - Oct. 31, 2016 ) -
Skip Section C
MID-YEAR ENROLLMENT/CHANGE :
q (Nov. 1, 2016 - Nov. 13, 2017) Check all applicable boxes. Please complete all appropriate sections, including Section C
for mid-year enrollment.
q Newly Eligible Employee: Hire date________________________ Benefit effective date if later than hire date _________________________
q Change - q Name q Address q Agency Transfer q Dependent q Direct Deposit
q DeCAP ONLY- Increase, Decrease or Terminate Contribution q HCFSA ONLY - Increase Contribution
q HCFSA ONLY - If you terminate your employment with the City of New York during the Plan Year and would like to elect Continuation Coverage, you may elect to deduct the
remaining balance of your goal amount on a pre-tax basis either by lump-sum or pro-rated payroll deductions, as long as the FSA Program Administrator is able to meet the payroll
deadlines for the applicable pay dates. Department of Education employees terminating employment in the summer must notify the FSA Program Administrative Office by the
second week in May.
Last pay date:
______ /______ /______
Last date at work:
______ /______ /______
SECTION A
Employee, Spouse and Dependent Information
1. EMPLOYEE (PARTICIPANT) INFORMATION
(ALL SECTIONS MUST BE COMPLETED.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
FEDERAL MARITAL STATUS
-
-
/
/
q Single
q Married
q Divorced
q Separated
q Legally Separated
AGENCY NAME (NOT DIVISION): (CUNY AND H+H EMPLOYEES PLEASE SPECIFY NAME OF COLLEGE OR HOSPITAL)
Check here
q
If you are on a weekly payroll.
LAST NAME
FIRST NAME
M.I.
HOME ADDRESS - NUMBER AND STREET
APT. NO.
CITY
STATE
ZIP CODE
WORK PHONE NUMBER
HOME PHONE NUMBER
MOBILE PHONE NUMBER
(
)
-
(
)
-
(
)
-
2. SPOUSE INFORMATION
(PLEASE NOTE: DOMESTIC PARTNERS/CIVIL UNIONS ARE NOT ELIGIBLE FOR THE FSA PROGRAM.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
EMPLOYMENT STATUS
*
Must provide proper documentation under DeCAP
**
Not eligible under DeCAP
***
Need description of occupation on letterhead stationery; or with no letterhead stationery, notarization is required
-
-
/
/
q Employed q Self-Employed*** q Full-Time Student* q Disabled* q Unemployed**
LAST NAME
FIRST NAME
M.I.
3. DEPENDENT INFORMATION
(LIST ALL YOUR ELIGIBLE DEPENDENTS. CHECK THIS BOX
IF ATTACHING AN ADDITIONAL PAGE.)
q
FOR DeCAP: THE DEPENDENT MUST BE CLAIMED ON YOUR INCOME TAX RETURN AND UNDER THE AGE OF 13.
LAST NAME
FIRST NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH
AGE
RELATIONSHIP TO EMPLOYEE
c
ac
dc
(CHECK ONE)
c
ac
dc
-
c
child under age 13
-
ac
child age 13 through
c
ac
dc
age 26
-
c
ac
dc
dc
disabled child
SECTION B
Annual Contribution
Amount*
(January 1, 2017 - December 31, 2017)
$____________________
Health Care Flexible Spending Account
Annual Contribution:
Minimum $260 - Maximum $2,600
HCFSA
*
Your DeCAP and HCFSA annual contribution amount will be prorated over each paycheck. Please note that CUNY and DOE/Q Bank will be prorated over 24 paychecks.
Annual Contribution:
Minimum $500 - Maximum $5,000
$_____________________
Dependent Care Assistance Program
DeCAP
(Note: If you are married and filing separate income tax returns, the maximum that you may allocate to DeCAP is $2,500.)
Does your spouse’s employer offer a DeCAP that you take part in?
No
Yes If Yes, Dollar Amount $_________
q
q
The total combined Plan Year dollar amount for you and your spouse cannot exceed
$5,000.
Please Sign Section F on Page 2.
Over
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business