Flexible Spending Arrangement Enrollment Form - University Of Ought Sound - 2016

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UPD
University of Puget Sound – Flexible Spending Arrangement Enrollment Form
Plan Year: 1/1/2016-12/31/2016
Last Day to Submit Claims: 3/31/2017
Employee Information –
Please write legibly to ensure proper enrollment
Last Name, First Name
SSN / Employee ID #
Home Address
Email Address
(Street, City, State, Zip Code)
Date of Birth
Phone Number
Effective Date (I
(MM/DD/YYYY)
f outside open enrollment)
Benefit Elections
# of
Paycheck
Section 125 Benefit
Yes/No
Annual Election
Paychecks
Deduction
Yes
Health Care FSA
Maximum of $2,550.00 per plan year
No
$_____________
$_________
Day Care FSA
Yes
Maximum of $5,000.00 per plan year
No
$_____________
$_________
(or $2,500 if you’re married and filing taxes separately)
Premium Conversion
The group insurance premiums you pay through your paycheck are
N/A
N/A
N/A
automatically deducted pre-tax. Premium contributions toward
Automatic
domestic partner coverage will be deducted post-tax unless they
qualify as a tax dependent.
Direct Deposit
Direct Deposit – Reimbursements are electronically
Account #:
deposited into your bank account. If you’ve previously
Yes
Checking
signed up for direct deposit your information will remain
No
Savings
Routing #:
on file and you do not need to complete this section.
Signature
This election form will remain in effect and cannot be revoked or changed during the plan year unless the revocation and new election are on account of and
consistent with federal regulations. I understand that Health FSA reimbursements will be available only for qualifying medical care expenses for myself, spouse,
and dependents. I also understand that Day Care reimbursements will be available only for qualifying day care expenses. I agree to notify the Employer if I have
reason to believe that any expense for which I have obtained reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Employer
on demand for any liability it may incur for failure to withhold federal, state or local income tax or Social Security tax from any reimbursement I receive of a non-
qualifying expense, up to the amount of additional tax actually owed by me. I understand the benefits and I have read the reverse page. I hereby authorize and
direct my employer to reduce my salary by the amount necessary to pay for the benefit(s) as shown above for the plan year indicated above.
YES, the above benefits have been explained to me and I elect to participate as indicated
NO, the above benefits have been explained to me and I decline participation
Employee Signature
Date
X
Completed Enrollment Forms must be returned to Human Resources
Please see the reverse side for important information regarding the above benefits

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