Flexible Reimbursement Account Enrollment Form printable pdf download

Flexible Reimbursement Account Enrollment Form

City of Stamford

Flexible Reimbursement Account

2015 ENROLLMENT FORM

Social Security Number: ______________________________ Employee ID#:_______________

Name: _____________________________________________Contact#____________________

Last

First

Middle

Address: _______________________________________________________________

Street

City

State

Zip

Date of Birth________________________

Date of Hire________________________

Effective Date_______________________

In accordance with my rights under the Plan, I elect the following benefits for the 2015 Plan Year. I

agree that my paycheck will be reduced by the amounts necessary to pay for my elected options.

Election for MEDICAL CARE Reimbursement

(Must re-enroll yearly)

( )

I elect to receive MEDICAL REIMBURSEMENTS for the Plan Year 2015. The

amount of salary redirection will be $_________________ for the Plan Year. (The total

amount cannot exceed $2,550.)

OFFICE USE ONLY

WEEKLY AMOUNT

$_________________

I understand that:

Reimbursement will be available only for “qualified medical care expenses.” Generally, “qualifying

medical care expenses” are those medical expenses normally deductible on my Federal Income tax

return (without regard to the percentage of adjust gross income limitation). I agree to notify the City of

Stamford, if I have reason to believe that any expense for which I have obtained reimbursement is not a

qualifying expense.

If I cease my employment with City of Stamford, my participation in the Plan will cease, subject to any

COBRA regulations. No further contributions will be made to the Plan on my behalf and I may be

entitled to reimbursements for claims incurred prior to my date of termination.

I understand that I cannot seek reimbursement from this account for a medical expense which I intend on

taking as a deduction on my tax return.

Page 1

(Note: This is a two page form. Both pages must be submitted)

Flexible Reimbursement Account Enrollment Form