FSA Change of Status Elecon Form
RETURN THIS COMPLETED FORM TO YOUR EMPLOYER.
For employer use only: Employers sponsoring the FSA may submit this form through the Employer Upload Site located at hps://www.mymidamerica.com/le-upload/employers/. Select Employer File Upload, then Census.
F2106-001 | MidAmerica FSA Change of Status Elecon Form (0621)
STEP 2
STEP 3
Type of Change
Reason for Change (Qualifying Event)
Choose carefully as your elecon is binding for the enre Plan Year. Any unused dollars remaining in your Flexible Spending Account at the end of the Plan Year may be forfeited
depending on your plan design. Addional rules regarding when expenses must be incurred in order to be eligible for reimbursement may also vary depending on your unique
FSA. For more details on your FSA, review your Plan Highlights. You can download your Plan Highlights by logging into your account at www.myMidAmericaJourney.com.
Valid qualifying events include, but are not limited to (choose one):
*You must make your elecon change within 30 days of the qualifying event.
Important note on documentaon: You must submit supporng documentaon corresponding with the qualifying event, such as a marriage, birth or death cercate; divorce
decree; leer from employer substanang employment status or change in coverage; leer from childcare provider substanang change in cost or provider.
NOTE: Enter eecve date of coverage:
NOTE: Enter eecve date of change in status*:
STEP 1
Parcipant Informaon
Employer
First Name Last Name
Email Address
Mailing Address
City State Zip Telephone
M.I.
Date of Birth (mm/dd/yyyy)
Social Security Number
Benet Type Current Annual Elecon
Current Per Pay Period
Withholding
New Annual Elecon
New Per Pay Period
Witholding
Health Care Reimbursement
$ $ $ $
Dependent Care Reimbursement
$ $ $ $
Change in Employment Status | Beginning/end of employment of a spouse resulng in a gain or loss of insurance coverage.
Change in Insurance Coverage, Cost, or Provider | This opon only applies to dependent care.
Change in Legal Marital Status| Marriage, divorce, or death of a spouse.
Gain or Loss of Other Group Health Coverage | Medicare/Medicaid, COBRA
Unpaid Leave of Absence
Change in Number of Tax Dependents | Birth, adopon/placement for adopon, gain/loss of dependent eligibility, or death of a dependent.
Judgement, Decree, or Court Order
Change in Employment Type |Changing from part-me to full-me employment or from full-me to part-me employment.
Parcipant Signature
Signature Date (mm/dd/yyyy)
STEP 4
Parcipant Cercaon & Signature
I hereby amend my Flexible Benets Plan elecon; therefore, I authorize my Employer to reduce my wages on a pre-tax basis during each payroll period in the amount noted above. I understand this elecon
will be in eect for only the current plan year. I understand I must complete each year. I understand that I cannot revoke or change this elecon during the Plan Year unless there is another change in status
qualifying event that aects my or my dependents’ eligibility under this Plan or another employer plan. The rules regarding elecon changes are described in more detail in the Plan Highlights. I understand
that I must submit a claim and appropriate substanang documentaon (e.g. explanaon of benets, itemized bill) for out-of-pocket medical, and/or Dependent Care expenses before I can be reimbursed.
I cerfy that I will only submit claims for reimbursement under the Flexible Spending Account Plan. I cerfy that I will not submit claims for reimbursement under the Flexible Spending Account Plan for
amounts that have already been reimbursed by another source nor will I seek reimbursement for such amounts from any other source.
