Personal Information:
Participant Name: Employer:
Mailing Address: Plan Year:
City/Town, State, ZIP: SSN: DOB:
E-Mail: Daytime Phone:
Employment/Payroll Info.: I am a (check one): Municipal Employee School Employee
I am paid (check one): Bi-weekly City (24) Bi-weekly Schools (_20)
Flexible Spending Account (FSA) Benefit Selections:
420 Washington St., Ste. 100
Braintree, MA 02184
Tel.: 781-848-9848
Authorization for Pre-Tax Payroll Reduction
Enrollment Deadline is _5_/22__/2020.
Late Enrollments not Accepted.
Health Care FSA Election: $_________ for the plan year
for employee, legal spouse, and eligible dependents’ quali-
fied medical, dental, vision expenses.
Benefit card included.
Max. Annual Election: $2,750.
Rollover Option: Any unspent Health Care balanceup to $500will
roll over to the next plan year if you re-enroll for the next plan year.
Ineligibility Note: You are NOT eligible for this plan if you or your
spouse have a Health Savings Account (“HSA”).
Dependent Care FSA Election: $_________ for the
plan year
for qualified childcare expenses of eligible
dependents under age 13, and elderly or special needs
dependents requiring day
Max. Annual Election: $5,000. per family
Claim-based plan; no benefit card. Participants must submit
claim(s) each plan year to receive accrued funds.
Direct Deposit Info. Direct deposit is Cafeteria Plan Advisors’ preferred method of expense reimbursement. Unless your
banking info. is already on file with Cafeteria Plan Advisors, please set up direct deposit: 1) Attach a voided check to this form;
or 2) Set up direct deposit online via your account portal once you receive enrollment confirmation.
Certification. I hereby authorize a salary reduction agreement for the amount(s) shown above and understand that:
Cafeteria Plan Advisors, Inc., will hold these funds until eligible expenses are incurred and a claim is submitted. FSA expenses must be consistent
with allowable deductions under Internal Revenue Service (IRS) Publication 969, and funds may be forfeited in accordance with the same publication
if eligible balance isn’t incurred and/or submitted for reimbursement by plan year deadline.
All claims for the Plan Year must be submitted within ninety (90) days of the end of the Plan Year.
Your Health Care FSA plan has a Rollover option. Eligible balances roll over to the next plan year when you re-enroll in the Health Care FSA for the new
plan year and the rollover occurs after the current plan year’s 90-day runout period ends.
This election cannot be revoked or changed during the plan year unless the participant experiences a qualifying event as defined by the IRS.
Current participants must enroll each plan year; re-enrollment is not automatic.
Health Care FSA cards, if offered through your employer’s plan, will reload at the start of each plan year when you re-enroll; keep until they expire.
Additional certification for Dependent Care Plan Participants: I understand that the Dependent Care Reimbursement Plan Guidelines can be found at
and I qualify to participate in the FSA Dependent Care plan. I agree to notify the plan administrator in writing within 30 days should I
experience a change in need or no longer meet the IRS’s eligibility criteria. Dependents must qualify under regulations set forth in IRC sections 152 and 129.
Tax advice: It is suggested you consult with a tax advisor to determine your tax savings and/or limits on tax deductions.
Signature: ______________________________________________________ Date: ________________________
A system-generated e-mail confirmation will be sent once your enrollment is processed.
City of Fitchburg
INSTRUCTIONS: New Enrollees: Complete & return this form to CPA, Inc., by e-mail ( or fax (781-848-8477).
If Already in Plan: Enroll for the new plan year online via your account portal. Go to, click
Sign In: Employee Online Access, log into your account, select ENROLL, and follow the steps.
HD-RO Ver. 1.1 (2/18/20)
click to sign
click to edit