Office Use Only:
2021 Flexible Spending Account
Employee Name (Last, First) Please print
Banner ID
Email/Access ID
Date of Birth
Work Phone
Home Phone
Check one: 12-Month Employee 9-Month Deferred Employee 9-Month Employee New Hire Open Enrollment
Health Care
Dependent Care
Allows you and your eligible
dependents to save tax dollars
on health care expenses.
Allows you to save tax dollars
on dependent day care
Maximum Annual Election
The lesser of:
for married
individuals filing a joint
return or for unmarried
for married
individuals filing
Your earned income.
Your spouse's earned
Your Annual Election
$ $
Please note: “Health Care Reimbursement Account” is referred to as “Medical FSA” and “Dependent Care
Reimbursement Account” is referred to as “Dependent Care FSA” by Discovery Benefits.
I authorize my employer to reduce my pay on a per-pay-period basis for the annual amount elected. I
understand my reduction is for one flexible spending plan year and that I cannot change or revoke my election
unless I experience a qualifying Life Status Change Event as defined by Internal Revenue Code Section 125 and
submit my request within 30 days of that event.
I am aware of the plan’s forfeiture provision and that any amount remaining in my account beyond the defined
deadline I will lose.
I understand that Social Security and Medicare taxes are not being withheld on the amount of the reduction
under this election.
If my employment terminates, only medical expenses incurred through my period of coverage as defined in the
Plan can be considered for reimbursement.
When using the debit card, I agree to use the card for eligible expenses only and will submit all itemized receipts.
Further, I authorize the release of any information necessary to substantiate claims submitted against my
Flexible Spending Account.
Employee Signature
Return to:
HR Service Center, 5700 Cass Ave., Suite 3638, Detroit, MI 48202; Fax: 313-577-0637; E-mail: askhr@wayne.edu. Use your WSU E-mail
and include “#SECURE” in the subject line to ensure your personal information is encrypted.
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