©ConnectYourCare Form 400001 (10/2014)
Flexible Spending Account Enrollment Form
Follow these easy steps:
1. Complete all entries on this Enrollment Form. Please print.
2. Sign and date this form.
3. Submit it to your Human Resources Department
Personal Information
Employee Name
(last name, first name)
Social Security Number
Street Address
(cannot be PO Box)
City, State, Zip Code
Mailing Address
(if different
)
City, State, Zip Code
Day Time Phone Number Email Address
Date of Birth (MM/DD/YYYY)
Enrollment Status New enrollment
Re-enrollment
Marital Status Single Married Divorced Widowed
Authorization and Certification
I understand that:
· I am authorizing my employer to reduce my compensation by the amount specified. This election will expire at the end of the plan year,
and I must make a new election each year.
· I am not permitted to change my elections during the plan year unless the change is due to and in accordance with certain recognized
IRS regulations for change in status events.
· I must report any administrative errors to my payroll administrator or human resources department within 10 days of my first payroll
deduction of the plan year.
· Funds left in my Dependent Care Account at the close of the plan year will be forfeited. Funds left in my Health Flexible Spending
Account may be forfeited, per plan rules. See plan documents for more details.
I will receive a ConnectYourCare Payment Card to access funds in my account. I certify that:
· The card will only be used for eligible medical and/ or dependent care expenses.
· Claims I pay with the card have not been reimbursed and I will not seek reimbursement from any other plan covering health or
dependent care benefits.
Employee Signature Date
For Employer Use
Date of Hire (MM/DD/YYYY)
Benefits Effective Date
(MM/DD/YYYY)
Health Flexible Spending Account (FSA)
Select FSA Decline FSA
I. Annual Contribution
(Not to exceed IRS limits*)
II. Number of regular pay periods
III. Contribution per pay period (I divided by II)
Dependent Care Assistance Plan (DCAP)
Select DCAP Decline DCAP
I. Annual Contribution
(Maximum Contribution: $5,000)
II. Number of regular pay periods
III. Contribution per pay period (I divided by II)
*Health FSA contributions are limited by the IRS. The limit is per person; a married couple may each contribute up to the specified limit.
