Florida Combined Life Fsa Employee Change Form Page 2
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1
2CHANGE IN CONTRIBUTION/PARTICIPATION
(Based upon key status changes outlined below)
Health Care Account And Dependent Care Account
Check Reason:
q
Legal marital status—marriage, divorce, death of spouse, legal separation, or annulment;
q
Number of dependents—birth, adoption, placement for adoption or death of a dependent;
q
Employment— change in employment status of employee, spouse or dependent to include termination or commencement of
employment by; a strike, lockout, commencement or return from an unpaid leave of absence, change in work site, switching from
part-time to full-time (or vice-versa);
q
Residence—a change in the residence of employee spouse or dependent;
q
Situations where a dependent satisfies or ceases to satisfy the rules for unmarried dependents—due to the attainment of age,
student status, or similar circumstances as provided in the plan;
q
Adoption Assistance—commencement or termination of adoption proceedings;
q
Certain Cost or Change in Coverage—changes in a spouse’s benefit program. (Most cost/coverage changes merely allow
adjustments in annual election amounts, but do not inherently constitute valid status changes.)
CHANGE IN CONTRIBUTION/PARTICIPATION
(Must parallel status changes outlined above)
MEDICAL
DEPENDENT CARE
Date of Change:
Date of Change:
Current Contribution Per Pay:
$
Current Contribution Per Pay
$
Current Annualized Amount:
$
Current Annualized Amount:
$
New Contribution Per Pay:
$
New Contribution Per Pay:
$
New Annualized Amount:
$
New Annualized Amount:
$
First Payroll Deduction Date:
First Payroll Deduction Date:
LEAVE OF ABSENCE
(To be completed by employer)
MEDICAL
DEPENDENT CARE
Leave Effective Date:
Leave Effective Date:
Final Payroll Deduction Date:
Final Payroll Deduction Date:
YTD Deduction Amount
$
YTD Deduction Amount:
$
Access to Annual Election: (Employer please check one).
q
Allow full access for remainder of Plan Year
q
Allow full access only for expenses incurred up through
leave of absence date.
(Must conform to published company policies)
PLEASE COMPLETE INFORMATION AND SIGN FRONT SIDE
Rev. 09/02
51090-600RPS
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