Flexible Spending Account Enrollment Form - 2016
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1Available only to employees working 20+hrs/ week & paid through Diocese of California’s Payroll System
EPISCOPAL DIOCESE OF CALIFORNIA
2016 FLEXIBLE SPENDING ACCOUNT ENROLLMENT
Name: __________________________________ Social Security No. : ________________
Email: ______________________________________________________________________
Phone: _________________________________ Fax: ________________________________
Home Address: _______________________________________________________________
_______________________________________________________________
Birth Date: _____________ Effective Date: ____________ Parish Code _______________
Yes! I wish to enroll in
Per Paycheck
Annual Deposit
Withholding
Health Care
$ _________________
Flexible Spending Account
$ ______________
The minimum annual deposit
annual amt divided by
is $100.
Indicate your annual deposit for
# of pay periods
The IRS set maximum annual
eligible medical expenses. . . .
remaining in year**
deposit is $2,550*
Annual Deposit
Per Paycheck
Yes! I wish to enroll in
Withholding
Dependent Care
$ ________
__
Flexible Spending Account
(The maximum annual deposit is
$ __________
$5,000; $2,500 if you are married
annual amt divided by # of
Indicate your annual deposit
and are filing separate income
pay periods remaining in
.
for eligible dependent expenses. .
tax returns.)
year
th
**There are 24 paychecks issued each year - 2x / month on 15
& last day of mo. Calculate the per paycheck withholding by dividing your annual
deposit by the number of remaining pay periods in the year. The total annual deposit is the before-tax amount that will be deducted in equal
installments from each paycheck.
I understand the elections made above are binding upon me for the plan year specified and cannot be changed unless I
have a qualified change in family status. I further understand payroll deductions will be made based on the elections
indicated and up to $500.00 of UNUSED MONEYS LEFT IN THE ACCOUNT WILL ROLL-OVER INTO THE NEXT
YEAR.
____________________
Date
Employee Signature
Complete and return enrollment form by email
or fax 415-673-4863
fsa enrollment form 2016
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