RCUH USE ONLY Authorized By: Coverage Start Input By / Date Edit By / Date
Flex
RCUH Form B-5F rev 10/27/15, 03/30/16, 02/21/18, 12/28/18, 05/17/19, 12/2/19
Research Corporation
of the University of Hawai‘i
Employee Name:
RCUH Employee ID #:
SECTION I: PRETAX Flexible Spending Plan Election & Compensation Reduction
IMPORTANT: PRIOR to completing this form, read the Election Information Sheet and RCUH’s Flexible Spending Plan information
brochure, OR refer to policy 3.530 RCUH Flexible Spending Plan. Select an option and indicate your election(s) below:
☐ Change Enrollment due to
1) Your election change must be submitted to the RCUH HR Department no later than thirty (30) days after a family status change.
2) Supporting documentation must be submitted to make changes to your enrollment.
Dependent Care Expense Account:
(Maximum contribution per pay period = $208.33 / pay period)
Maximum Annual Contributions: $5,000 (2020)
$
/ Pay Period
SECTION II: PRETAX Transportation Benefits
IMPORTANT: PRIOR to electing, changing, or canceling this coverage, read RCUH policy 3.530A RCUH Flexible Spending
Plan. These elections can be made at any time throughout the calendar year, but must be submitted to the RCUH HR Department at
least 30 days PRIOR to the requested effective date. Select an option and indicate your election(s) below:
Parking Expense Reimbursement
☐ Enrollment $ / Month
(Maximum Annual Limit Per Month: $270.00 / month)
☐ Change $ / Month
☐ Cancel: Parking Expense Reimbursement
Transit Expense Reimbursement
Deduction occurs the month prior to coverage
Enrollment $ / Month
(Maximum Annual Limit Per Month: $270.00 / month)
☐ Change $ / Month
☐ Cancel: Transit Expense Reimbursement
The Effective Date will be dependent upon submission of this form to RCUH Human Resources.
RCUH will send a confirmation email with the effective enrollment date.
SECTION III: Employee Certification
I acknowledge that I have reviewed and understand the options available to me for my Employer's Flexible Spending Plan pursuant to the following: (1) RCUH Policy 3.530 Flexible
Spending Plan (2) Internal Revenue Service Code 125 for Pre-Tax Flexible Spending Accounts and/or (3) Internal Revenue Service Code 132 for Pre-Tax Transportation Accounts
and will comply accordingly.
I understand that my Employer makes no guarantee that any benefits I elect under this Plan will be excludable from my gross income for federal or state income tax purposes. I
understand that it is my obligation to determine whether or not each payment made under this Plan is excludable from my gross income for federal and state income or Social
Security tax and to notify my Employer if I am aware that any particular payment may not be excludable. I agree that if I receive one or more reimbursements under this Plan
that are not excludable from income under the Internal Revenue Code, I will indemnify and reimburse my Employer for any tax that may be due on such reimbursement.
I understand that failure to comply with the above or providing inaccurate information or falsifying the information contained in this form may result in disciplinary action
including termination of employment. Legal action may be brought against me and/or my Dependents/Spouse/Domestic Partner/Civil Union Partner for any losses, damages
(including, but not limited to reasonable attorneys’ fees and other legal expenses), financial or otherwise, due to false statements provided on this enrollment form or for failure
to timely notify RCUH of changed circumstances as required.
Employee Signature: Date:
3.530 RCUH Flexible Spending Plan
RCUH Flexible Spending Enrollment & Change Form (B-5F)
Submit via email: RCUH_Benefits@RCUH.com or Fax: 808-956-5022
Healthcare Expense Reimbursement Account:
(Maximum contribution per pay period = $114.58 / pay period)
Maximum Annual Contributions: $2,750 (2020)
RCUH is committed to protecting the security of your personal information.
Please submit via encrypted email to: rcuh_benefits@rcuh.com or FAX: 808-956-5022
RCUH will only accept wet signatures and will validate the information prior to processing
Choose Applicable Family Status Change Event
