SUNY Orange, Human Resources 115 South Street Middletown, New York 10940 Telephone 341-4660
2017 Flexible Spending Accounts Enrollment
Orange County Community College Section 125 Flexible Benefit Plan
Plan Year Coverage 01/01/17 – 12/31/17
Name (print) Social Security Number______/____/_____ DOB: ________________
Mailing Address
Street or PO Box City State Zip Code
I hereby elect to make an annual contribution to the flexible spending account(s) under the Plan and agree that the annual contribution will
be made in equal amounts* each pay period through payroll deductions. If an odd deduction is required to meet you pledge amount, it will
be the first deduction of 2017.
1. ( ) HEALTH CARE FLEXIBLE SPENDING ACCOUNT (Health FSA – IRS 125) $ _____________ total for the plan year.
The minimum annual deposit in the Health Care Flexible Spending Account is $300 and the maximum cannot exceed $2550.
2. ( ) DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (IRS 129) $_____________________ total for the plan year.
The minimum annual deposit in the Dependent Care Flexible Spending Account is $300 and the maximum cannot exceed
$5,000. ($300 minimum and $2,500 for married participants who file separate returns.)
DEPENDENT(S) INFORMATION
I agree that my compensation will be reduced by the amount of my required contribution for the benefits I have elected under the
Orange County Community College Section 125 Flexible Benefit Plan, and that such salary reductions will continue for each pay
period until this agreement is amended or terminated. I understand that:
I cannot change or revoke this Salary Reduction Agreement as of any date prior to the next Plan Year, unless a Change in Status, as
permitted under the Internal Revenue Code, occurs. Documentation consistent with this request must be provided.
Salary Reductions under this Salary Reduction Agreement will reduce my compensation for Social Security tax purposes.
Eligible expenses must be incurred by 12/31/17. Claims must be submitted on or before 3/31/18. Unused funds will be forfeited.
If I do not complete and return a new election form during next Open Enrollment, my participation in the Flexible Spending Program will
terminate December 31, 2017.
If I am enrolled in a Health FSA, and go out on a Leave of Absence, or separate from employment, I must notify Human Resources.
_____________________________________________ ______________________
Signature of Participant Date
