Fillable Flexible Spending Arrangement Enrollment Form - University Of Ought Sound

Additional Information

Premium Conversion

 If the enrollment status is marked as ‘AUTOMATIC’, you must notify your employer in writing to decline enrollment in this benefit. Premium

Conversion is subject to the change in status rules and is considered an election equal to the amount of your premium deductions.

Health Care Flexible Spending Arrangement (“Health Care FSA”)

 Reimbursement will only be available for qualifying medical care expenses as set forth in the Plan Document and Section 213 of the Internal Revenue

Code. It is your responsibility to check the eligibility of an expense prior to enrollment.

 Group Medical Plan Premiums cannot be reimbursed through the Health Care FSA and will be deducted pre-tax through the Premium Conversion

Plan. Therefore, do not include the cost of premiums in your FSA annual election amount.

Day Care Flexible Spending Arrangement (“Day Care FSA”)

 Reimbursement will be available only for qualifying day care expenses as described in the Internal Revenue Code Section 129, the Plan document and

the Summary Plan Description.

 Participation in a Day Care FSA will require you to complete tax form 2441 when filing federal taxes. If your plan includes a Grace Period any amounts

carried forward or forfeited during a taxable year should be entered in Line 13 of Form 2441. If you or your spouse is a full-time student, please

consult IRS Publication 503.

 If the Plan Year is less than twelve (12) months, the plan limit may be prorated to be less than the $5,000 calendar year limit mandated by the IRS.

Use-It or Lose-It

 You must claim all elected funds by the end of the run-out period. Money left in the plan after the end of the run-out period cannot be refunded to

you; this is referred to as the Use-it or Lose-it rule.

Claim Runout Period

 The claim runout period allows you to submit claims after the end of the plan year. Claims received after this period will be denied.

Lost Checks and Reissues

 Lost or stale dated FSA checks can be reissued 10 business days after the original check date. There is a $25.00 check reissue fee. The check reissue

request will require at least one business day to process.

 Any fees associated with presenting a canceled check will be deducted from your FSA as well as the face value of the check.

Direct Deposit

 All electronic funds transfers (EFT) will be initiated on the same day as the normal check reimbursement date. Deposits may take up to two (2)

business days to appear in the designated account.

 Returned items due to incorrect banking information will be assessed a $10.00 fee that will be deducted from your FSA balance.

Deductions

 FSA deductions will be deducted from your paycheck evenly throughout the plan year. You must indicate an annual election and a per paycheck

deduction on your enrollment form. If you enroll in the plan after open enrollment then please divide your annual election by the remaining

deductions in the plan year.

Change in Status

 All elections set forth are considered irrevocable for the entire plan year unless there is a qualifying change in status. Please consult the plan

document or summary plan description for a list of qualifying events.

 In the event of a change in status the change in election must be necessitated by and consistent with the change in status and the change must be

acceptable under IRS Regulations.

Eligibility

 Independent contractors and self-employed individuals are not eligible to participate in the Plan. Self-employed individuals include: Sole Proprietors

of their own business; General Partners in a general partnership and General Partners in a limited partnership; Limited Partners of partnerships with

guaranteed payments; more than 2% Shareholders of an S corporation as well as the spouse, children, parents and grandparents of a more than 2%

Shareholder; and non-employee Members of an LLC. It is your responsibility to determine your eligibility.

 Expenses must be incurred during the plan year and while you are an active participant in the plan. Any expense incurred prior to your effective date

or after your termination date cannot be reimbursed.

Electronic Disclosure Notice

 By providing your email address you consent to receive email communications from Navia, agents, and subcontractors regarding the Plan.

 If you no longer wish to receive information electronically, you may withdraw consent at any time at no cost. To withdraw consent, please contact

Navia.

 You have a right to receive a paper version of an electronically furnished document at no cost.

 To access documents you must have Adobe Reader. A link to download this software will be provided with all electronic documents provided.

Flexible Spending Arrangement Enrollment Form - University Of Ought Sound - 2016 Page 2

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