Company Name:
Employee Name: SSN:
Home Address:
City: State:
Zip:
Telephone:
Plan Year through
Date of Birth: Date of Hire: Effective Date:
The company and I hereby agree that my cash compensation will be redirected by the amounts set forth below for each pay period during the plan
year (or during such portion of the year as remains after the date of this agreement). I understand that if I do not return this form to my employer by
my effective date, it shall constitute my election to waive participation in all flexible spending programs under my employer’s Flexible Benefits Plan
and therefore cause me to pay non-reimbursable medical, dependent care, and/or commuter expenses (if any) with after tax dollars.
EMPLOYEE’S FLEXIBLE BENEFIT PER DAY DEDUCTION/ALLOCATION
MEDICAL FLEXIBLE SPENDING ACCOUNT
DEPENDENT CARE SPENDING ACCOUNT
$
Maximum ANNUAL Contribution
COMMUTER REIMBURSEMENT ACCOUNT
PARKING
$ Maximum MONTHLY Contribution
TRANSIT
$ Maximum MONTHLY Contribution
Per pay contribution: $ Date of first payroll:
Annual contribution: $ Number of remaining pays:
Per pay contribution: $ Date of first payroll:
Annual contribution: $ Number of remaining pays:
Per pay contribution: $ Date of first payroll:
Annual contribution: $ Number of remaining pays:
Full Flexible Spending Account
$
Maximum ANNUAL Contribution
Per pay contribution: $ Date of first payroll:
Annual contribution: $ Number of remaining pays:
Limited Purpose Flexible Spending
$
Maximum ANNUAL Contribution
Per pay contribution: $ Date of first payroll:
Annual contribution: $ Number of remaining pays:
Employee Email Address:
Location:
Account
(i.e., vision and dental only)
•
HIDE
•
REVEAL
Limited Purpose
•
HIDE
•
REVEAL
DCA
•
HIDE
•
REVEAL
FOR
OFFICE
USE
ONLY
•
Remove
Hide/Reveal
Control Panel
CRA
•
HIDE
•
REVEAL
Medical
FSA
Full
Flexible Spending Account Enrollment Form
FSA_DCA_CRA_enroll_2015v.1
TOLL FREE: 888.868.FLEX (3539) myameriflex.com
I UNDERSTAND THAT:
(1) My accounts will not automatically renew. During each annual open enrollment period, I understand that I must complete a new enrollment form
indicating my account contributions for the new plan year.
(2) I cannot change or revoke this agreement at any time during the plan year unless I have a change in family status (including marriage, divorce,
death of a spouse or child, birth or adoption of a child, termination or commencement of employment of a spouse, or such other events as the Plan
Administrator determines will permit a change or revocation of an election). Note: This does not apply to Commuter Reimbursement Accounts.
(3) The Plan Administrator may reduce, cancel, or otherwise modify this agreement in the event he/she believes it is advisable in order to satisfy
certain provisions of the Internal Revenue Code.
This agreement is subject to the terms of the Company’s Flexible Benefits Plan, as amended from time to time, which shall be governed under applicable
laws, and revokes any prior agreement relating to such plan(s).
By signing this form I agree to the terms and procedures listed herein.
I was given the opportunity to participate in this Flexible Benefits Plan, and I have decided not to participate at this time.
Employee Signature Date
