Flexible Spending Arrangement Enrollment Form

Download a blank fillable Flexible Spending Arrangement Enrollment Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Flexible Spending Arrangement Enrollment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

State of Louisiana
2015
Office of Group Benefits - Flexible Benefits Plan
Flexible Spending Arrangement Enrollment Form
You must complete this form each year to participate in a tax-free Flexible Spending Arrangement. Please print hard, using a ballpoint pen.
Social Security Number
Email Address
Payroll System
Agency Number
Last Name (Print)
First Name
Middle Initial
Home Address
City
State
Zip
Payroll Use ONLY
Home Phone
Daytime Phone
Date of Hire
Number of Pay Periods Date of Birth
Annual Salary
Effective Date First Payroll Date
ENROLLMENT STATUS - Check One: ______ CHANGE IN STATUS ______ ANNUAL ENROLLMENT ______ NEW HIRE
Indicate the amount you wish to set aside via tax-free salary deduction by completing the sections below. Complete the worksheets provided in the
Flexible Spending Arrangement (FSA) Handbook before deciding on the amount.
In Box #1, indicate the dollar amount you elect to contribute for the plan year.
In Box #2, indicate the number of regular payroll checks you expect to receive during the plan year (9, 10, 12,18, 24).*
In Box #3, indicate the deduction amount per paycheck. (Note: If Box #2 times Box #3 does not equal Box #1 exactly, the amount in Box #3 may be
changed slightly, to reflect rounding. By signing this form, you certify that you expect to receive the number of paychecks listed in Box #2.)
In Box #4, indicate the annual FSA fee amount (12 months = $36).
In Box #5, indicate the FSA fee per pay period (paid biweekly is $1.50; paid monthly is $3).
*If you are a new employee enrolling after the plan year begins, divide by the number of pay periods remaining in the plan year.
Dollar
Number of Regular
Deduction Amount
Annual FSA Fee
FSA Fee per
Type
Amount
Payroll Checks
per Paycheck
Amount
Pay Period
General-Purpose Health Care FSA (GPFSA)
For eligible medical expenses incurred by you, your family members, or both ($600 minimum contribution; $2,550 maximum contribution).
Limited-Purpose Health Care FSA (LPFSA)
For eligible dental and vision expenses only incurred by you, your family members, or both. For employees who want to participate in an FSA and a Health
Savings Account. ($600 minimum contribution; $2,550 maximum contribution).
Dependent Care FSA (DCFSA)
For eligible dependent care expenses of an eligible dependent while you work ($600 minimum contribution)
TAX FILING STATUS - CHECK ONE: ______ Married, filing separately (maximum $2,500) ______ Married, filing jointly (maximum $5,000)
______ Married with incapacitated spouse (maximum $5,000) ______ Single head of household (maximum $5,000) ______ Single (maximum $2,500)
IMPORTANT: SALARY REDUCTION AGREEMENT
1. I hereby authorize my employer to reduce my gross salary (before federal and state income taxes are calculated) by the total deduction
amount per pay period as indicated above. If applicable, I understand that this salary reduction might produce lower Social Security
benefits.
2. I agree to file IRS Form 2441 regarding my Dependent Care FSA.
3. I understand that any amount remaining in any FSA not used during this plan year will be forfeited since it cannot be carried forward to
the next plan year (due to the IRS "use-or-lose" rule).
4. I understand that funds in one FSA cannot be used to reimburse expenses covered by another FSA.
5. I understand that expenses for which I am reimbursed cannot be deducted on my income tax return.
6. I understand that funds in any FSA can only be paid out for reimbursement of eligible expenses actually incurred during my period
of coverage.
7. I understand that the salary deduction amount will include the items specified above and will continue in effect unless I terminate
employment or file an approved Change in Status form with the Human Resources office of my employer.
8. I understand and agree that my employer, the Office of Group Benefits and the Flexible Benefits Plan administrator will not incur any
liability resulting from either my participation in any FSA or my failure to sign or accurately complete this enrollment form. I further
understand that if I elect not to participate in salary deduction with respect to the benefits listed above, I hereby forego my right to
participate during the upcoming plan year.
Employee Signature
Agency or Payroll System Name
Date Signed
Payroll Officer/Benefits Administrator
Phone Number
OGB Agency Number
Date Signed
SUBMIT COMPLETED FORM TO YOUR HUMAN RESOURCES OFFICE
Revised 10/14
OGB FLEXIBLE BENEFITS PLAN
Print Form
Reset Form

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go