Flexible Benefits Plan Change-In-Status Form printable pdf download

Flexible Benefits Plan

Change-in-Status Form

EMPLOYEE INFORMATION

(Please Print)

First Name _________________________ Last Name ________________________________ MI ______Gender __________

Date of Birth _________________ Marital Status ______________________ Home Telephone ___________________________

Employer _______________________________________________________________ Work Telephone _________________

Email _____________________________________ Mailing Address ______________________________________________

City ________________________________________ State _____________________________ Zip ____________________

As a participant in the Flexible Spending Plan, I understand that I may make an election change if, under the facts and

circumstances, (i) a “Change-in-Status event” occurs, and (ii) the requested election change satisfies the consistency rules set

forth in the Plan Document.

I certify that I have incurred the following change in status, and that the requested change is on account of and consistent with the

Change-in-Status event checked below:

q Legal Marital Status (marriage, death of a spouse, divorce, legal separation)

q Number of Dependents (birth, adoption, or death of a dependent)

q Employment Status (changes in employment status of employee or spouse such as termination, commencement of

employment or a change in work schedule, e.g., a switch between part-time and full-time employment)

q Unmarried Dependents (dependent now satisfies or ceases to satisfy requirements for coverage due to age, student status or

other circumstances)

q Residence (change in place of residence or work of the employee, spouse, or dependent)

q Significant change in coverage or cost under my or my spouse’s plan (does not apply to Healthcare Flexible Spending Account)

q Other __________________________________________ (must be permitted by IRS rules and the Plan Document)

TERMINATION

I hereby request and authorize my employer to terminate my participation in the following benefit(s):

q Healthcare Flexible Spending Account

Effective Date ____________

q Dependent Care Reimbursement Account

Effective Date ____________

CHANGE

I hereby request and authorize my employer to change my participation in, and salary reduction amount for, the remainder of this

Plan Year as follows:

q Healthcare Flexible Spending Account

Effective Date of Change _____________

$________________________ x ________________________= $ ________________________

(Current amount being

(# of pay periods to date)

( “To-date” contributions)

deducted per pay period)

NOTE: “To-date”

$________________________ x ________________________= $ ________________________

contributions plus

(New amount to be

(# of pay periods remaining in Plan Year)

(New election amount)

deducted per pay period)

new election amount

must not exceed

q D ependent Care Reimbursement Account

Effective Date of Change _____________

Plan Year maximum.

$________________________ x ________________________= $ ________________________

(Current amount being

(# of pay periods to date)

( “To-date” contributions)

deducted per pay period)

$________________________ x ________________________= $ ________________________

(New amount to be

(# of pay periods remaining in Plan Year)

(New election amount)

(continued on reverse side)

deducted per pay period)

FSA-6 (Rev 7/13)

Flexible Benefits Plan Change-In-Status Form

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