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SECTION C Mid-Year Qualifying Event Enrollment/Change
Please indicate the Qualifying Event incurred and attach appropriate documentation. All Qualifying Events MUST be submitted with appropriate documentation in order to be
processed. This change must be consistent with your Qualifying Event and described on Page 3 of this Enrollment/Change Form. You must return this form within 30 days
after the Qualifying Event indicated below.
Qualifying Event (Please Write): Qualifying Event Date:
/ /
HCFSA and DeCAP - Qualifying Events and Required Documentation DeCAP Only - Qualifying Events and Required Documentation
• Marriage - Marriage certicate
• Birth of a child - Birth certicate
• Death of participant - Death certicate
• Adoption of a child - Adoption agreement and employee’s tax return showing eligible
dependents
• New employee - Letter from employer/agency
• Termination of employment (self) - Letter from employer/agency
• Approved unpaid leave of absence (during Open Enrollment Period) - Letter from
employer/agency
• Divorce/legal separation/annulment - Divorce, annulment decree/separation agreement
• Death (spouse or dependent) - Death certicate
• Change from FT to PT employment or vice versa-Letter from employer/agency (self,
spouse)
• Approved unpaid leave of absence - Letter from employer/agency (self, spouse)
• Termination of employment - Letter from employer (self, spouse)
• Reduction or increase of hours worked - Letter from employer (self, spouse)
• Ineligibility of dependent - Birth certicate or other appropriate documentation
SECTION D Direct Deposit Information - (MUST ATTACH VOIDED CHECK)
*ABA NUMBER: CHECKING ACCOUNT - THE ABA NUMBER IS THE FIRST NINE (9) NUMBERS PRIOR TO THE ACCOUNT NUMBER AT THE BOTTOM LEFT CORNER OF THE CHECK. SAVINGS ACCOUNT - CONTACT YOUR BANK FOR THE
ABA NUMBER, IF NOT KNOWN. **ACCOUNT NUMBER: SEE CHECK, PASSBOOK, OR ACCOUNT STATEMENT FOR ACCOUNT NUMBER.
Account Type:
(Check only one)
q Checking
q Savings
Person(s) Named on Account (Please Print Clearly) ABA Number* (Must be 9 Digits)
Attach
VOIDED
Check Here
Person 1: ___________________________________________________________________________
Person 2: ___________________________________________________________________________
Account Number** (Please Write)
SECTION E Authorizations, Annual Salary Reduction Agreement and Certication of Qualifying Event
Authorization and Annual Salary Reduction Agreement
I have read the printed material explaining the HCFSA and/or DeCAP benets and my choices under these programs. I have also read the Enrollment/Change Form information on Pages
3 and 4 of this form. I understand that by signing and submitting this Enrollment/Change Form, I am making a binding election as to my benet coverage for the Plan Year that begins
on January 1, 2020. I authorize my Employer to reduce my gross salary as indicated on this form in order to pay for the benets I have elected. I understand that my payments will be
pro-rated over each payroll period.
NOTE: I understand that my HCFSA election cannot be reduced or revoked for any reason except for termination of employment during the Plan Year, or if I should take an unpaid leave
of absence. I agree to pay, in full, the amount elected on this form for the Plan Year for HCFSA, by recalculating the payroll deductions upon returning from unpaid leave. My HCFSA
and/or DeCAP election can only be changed if I experience a Qualifying Event (Section C). I further understand that each account is separate and that DeCAP funds cannot be used
for or transferred to HCFSA or vice-versa. I understand that any amount remaining in these FSAs that is not used during the Plan Year and HCFSA Grace Period, if applicable, will be
permanently forfeited by me. I understand that I am only eligible to receive reimbursement on behalf of my eligible dependents listed on this form.
I understand that I will be terminated from participation in the Program if I cease employment with the City of New York or go on an unpaid leave of absence, unless I elect to participate
in the Continuation Coverage for HCFSA.
Direct Deposit Authorization
I hereby authorize the Flexible Spending Accounts Program to deposit my HCFSA/DeCAP reimbursement directly into my checking or savings account as requested. I also grant au-
thorization for the reversal of a credit to my account in the event the credit was made in error. I understand that, under the “National Automated Clearing House Association” operating
guidelines and rules, the Flexible Spending Accounts Program can only reverse the amount of the incorrect direct deposit. I agree that this authorization will remain in effect until I provide
to the Flexible Spending Accounts Program a written cancellation to terminate the service. I will notify the Flexible Spending Accounts Program if my bank account numbers listed above
should change.
Mid-Year Qualifying Event
This is to certify that I incurred the Qualifying Event indicated in Section C and, therefore, wish to modify my benets as indicated. I understand that the change(s) in benets requested
must be consistent with the Qualifying Event, and that I must provide approved documentation of all change(s), and that the effective date of the change(s) will be the date the forms are
received by the Plan Administrator or the date of my rst payroll deduction if I become eligible after the beginning of the Plan Year. The participant has the burden of proof to show that
the Qualifying Event is acceptable under the Plan. The Plan Administrator reserves the right to request additional information. The Plan Administrator has, among other duties, the power
and duty to interpret the Qualifying Event and to resolve ambiguities, inconsistencies and omissions.
SECTION F Employee/Participant Signature
SIGNATURE: DATE:
/ /
Return completed
form to:
City of New York Flexible Spending Accounts Program - 2020
Bowling Green Station, P.O. Box 707
New York, NY 10274
Retain a copy for your records
DO NOT WRITE IN THIS AREA
Payroll Database Agency Payroll Code
Program Initials Date PMS DOC# Other Payroll Initials Date
HCFSA / / / /
New York State I.D. Number
DeCAP / / / /