MEDICAL REIMBURSEMENT ACCOUNT
I elect to participate (not to exceed employer limit of $
2550)
$ ____________ Calendar Year
DEPENDENT CARE ACCOUNT
I elect to participate (not to exceed $5000 or $2500 if married ling separately)
$ ____________ Calendar Year
DIRECT DEPOSIT (
optional - for reimbursement into bank account in lieu of using debit card)
I elect to participate (there is no need to complete this section, unless you are changing accounts)
checking account OR
savings account
Financial Institution (name of bank): ________________________________________
Routing Number (always 9 digits): Account Number: ______________________
If you would prefer, you can attach a voided check.
TEAR ALONG THIS LINE
I request that my periodic paychecks for the plan year be reduced on a pro rata pre-tax basis by the sum of my medical reimbursement, dependent care and premium contributions to the plan,
with such amount to be allocated among the benets I selected above. I understand this election form cannot be revoked or changed during the plan year unless there is a qualied change in
status as dened in the Summary Plan Description (SPD). I certify that I will only claim reimbursement for eligible expenses for myself and/or qualied dependents as dened in the SPD. I further
certify that these expenses will not be reimbursed under any other benet plan. I understand any unused dollars remaining in my account(s) at the end of the plan year will be forfeited. I have
examined this agreement and to the best of my knowledge, it is true, correct and complete.
Employee Signature _____________________________________________________ Date ___________________
CHECK EXAMPLE
A123456789 A0000123456 A1234
routing number account number check number
PLEASE PRINT CLEARLY TO ENSURE ACCURATE ENROLLMENT AND FUTURE COMMUNICATION.
Employer Name: Eastern Michigan University EMU Employee ID#
Participant First Name: _________________________________ Last Name: _________________________________
Social Security #: Date of Birth: _________ /_________ /__________
Address: _________________________________________________________________________________________
City, State, Zip: _________________________________________________ Phone Number: ____________________
E-mail Address: ______________________________________ (Notication of direct deposit payment is sent via e-mail)
Pay Period: Semi-Monthly (twice a month) Bi-Weekly (every other week)
EMPLOYER USE
Please complete for mid-year enrollments
Date of rst deduction: _________________ Eligibility date:_________________
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