Dependent Care/health Care Reimbursement Account Plans Enrollment Authorization Page 2

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The California State University

DEPENDENT CARE/HEALTH CARE REIMBURSEMENT ACCOUNT PLANS

ENROLLMENT AUTHORIZATION

(REV. 08/2012) (REVERSE)

PRIVACY NOTICE

The Information Practice Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (Public Law 93-579) require that this notice be provided

when collecting personal information from individuals.

Information requested on this form is used by the State Controller’s Office and the program administrator, for the purposes of identification and

account processing.

It is mandatory to furnish all information requested on this form except for employee’s gender and marital status, which may be furnished on a

voluntary basis. Failure to provide the mandatory information may result in the DCRA and/or HCRA enrollment action(s) not being processed or

being processed incorrectly.

The State Controller’s Office requires the employee’s social security number and name for identification purposes. Legal references authorizing

maintenance of this information include Government Code Sections 1151 and 1153, Sections 6011 and 6051 of the Internal Revenue Code, and

Regulation 4, Section 404.1256, Code of Federal Regulations, under Section 218, Title II of the Social Security Act.

Information provided on the form will be forwarded to the Claims administrator. Copies of the Dependent Care/Health Care Reimbursement Account

Plan(s) Enrollment Authorization Form(s) are maintained in confidential files of the State Controller’s Office for five years. Employees have the right

of access to copies of their Dependent Care and/or Health Care Reimbursement Account Plan(s) Enrollment Authorization forms upon request. The

official responsible for the maintenance of the forms is: Chief of Personnel/Payroll Operations Bureau, State Controller’s Office, P. O. Box 942850,

Sacramento, California 94250-5878, Attention: Benefits Unit.