Fillable FBMC2014 Enrollment Form (Southwest Tennessee Community College)

Fill Online, Printable, Fillable, Blank FBMC2014 Enrollment Form (Southwest Tennessee Community College) Form

Use Fill to complete blank online SOUTHWEST TENNESSEE COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FBMC2014 Enrollment Form (Southwest Tennessee Community College)

On average this form takes 7 minutes to complete

The FBMC2014 Enrollment Form (Southwest Tennessee Community College) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 29 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Southwest Tennessee Community College

BROWSE SOUTHWEST TENNESSEE COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Important
• Iunderstandthatthisisnotanapplicationforinsurance.Toenrollorchangemymedicalordentalinsurance,Imustcompletetheproperinsuranceforms.
• Iherebyauthorizemyemployertoreducemygrosssalarybeforefederal,stateandsocialsecuritytaxesarecalculatedbythetotalamountofannualsalaryreductionindicatedabove.
• IunderstandthecontributiontomySocialSecurityaccountwillbereduced,sincecontributionswillbebasedonmyincomeafterreduction.
• I understand that any amount remaining in any Flexible Spending Account that is not used during the plan year will be forfeited since it cannot be carried forward to the next
plan year.
• IunderstandthatthefundsinoneFSAaccountcannotbeusedtoreimburseexpensescoveredbyanotheraccount.
• IunderstandthatexpensesforwhichIamreimbursedcannotbedeductedonmyincometaxreturns.
• IunderstandthatthefundsintheFSAaccountcanonlybepaidouttoreimbursepaymentofeligibleexpensesactuallyincurredduringtheplanyear.
• IunderstandthattheamountofsalarydeductionwillincludetheitemsspeciedaboveandwillcontinueineffectunlessIterminateemploymentorleanapprovedchangeinstatus,within90daysofa
qualifyingevent.
• IunderstandandagreethatmyemployerandFringeBenetsManagementCompany,aDivisionofWageWorks,willnotincuranyliabilityresultingfromeithermyparticipationinormyfailuretosignor
accuratelycompletethisEnrollmentForm.IfurtherunderstandthatifIelectnottoparticipateinsalaryreductionwithrespecttothebenetslistedabove,Iherebyforegomyrighttoparticipateduringthe
upcomingplanyear,unlessotherwiseprovidedbylaw.
• IunderstandthatImaybeaskedbytheIRStoprovidetheFEInumberofmydaycareprovider.
 I certify that: 1) I will only use my FSA to pay for IRS-qualified expenses and only for my IRS-eligible dependents, 2) I will exhaust all other sources of reimbursement, including
those provided under my Employer’s plans before seeking reimbursement from my FSA, 3) I will not seek reimbursement through any other source, and 4) I will collect and
maintain sufficient documentation to validate the foregoing.
CompletetheworksheetsprovidedinyourReferenceGuidebeforedecidingontheamount(s)tobeenteredinthesectionsbelow.Ifyouhave
questions,consultyourReferenceGuide,orcallCustomerCareat1-800-342-8017.YoumayalsocontactCustomerCareatwww.myFBMC.com.
InBox#1,indicatethetotaldollaramountyouelecttocontributeforthe PlanYear.InBox#2,indicatethenumberofregularpayrollchecksyouexpecttoreceiveduringthe
PlanYear(consultyourpayrollofceifyouareunsureofhowmanychecksyouwillreceive).InBox#3,indicatethereductionamountperpayperiod.
()
CustomerCare1-800-342-80177a.m.-10p.m.
12 2624
WORKPHONE HOMEPHONE HOMEADDRESS[STREET] CITY STATE ZIP
LASTNAME FIRSTNAME M SOCIALSECURITYNUMBER
PAYCHECKEFF.DATE:
(FOR OFFICE USE ONLY)




DATEEMPLOYED DEPT.CODE
EFFECTIVEDATE

S
T
A
T
E
U
N
I
V
E
R
S
I
T
Y
&
C
O
M
M
U
N
I
T
Y
C
O
L
L
E
G
E
•
S
Y
S
T
E
M
O
F
T
E
N
N
E
S
S
E
E
MCML XXII
T
E
N
N
E
S
S
E
B
O
A
R
D
O
F
R
E
G
E
N
T
S
Enrollment
Status:
NewEnrollment
Re-enrollment
E-MAILADDRESS
EmployeeSignature DateSigned

()
PAYROLLFREQUENCY
(Refertolistinyour
ReferenceGuide,
availableat

Maximumallowableannualcontributionis$2,500peremployee.
Box#1
Total PlanYearDollarAmount
_________________
Box#2
NumberofRegularPaychecksExpected 
Box#3
ReductionPerRegularPaycheck


TAXFILINGSTATUS [PLEASE CHECK ONE]:
o Married,lingseparately
[maximum-$2,500]
oMarried,lingjointly
[maximum-$5,000]
oSingle,headof
household
[maximum-$5,000]
Box#1
Total PlanYearDollarAmount
________________
Box#2
NumberofRegularPaychecksExpected 
Box#3
ReductionPerRegularPaycheck

2014
2014
RESET
70
01/01/2014
PRINT FORM, SIGN AND RETURN TO HUMAN RESOURCES
10/03/2013
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FBMC2014 Enrollment Form (Southwest Tennessee Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document