RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII
RCUH FLEXIBLE SPENDING PLAN ELECTION & COMPENSATION / CHANGE FORM (50-100% FTE)
Submit via email: RCUH_Benefits@RCUH.com or Fax: 808-956-5022
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RCUH USE ONLY Authorized By:
RCUH Form B-5F rev 10/27/15
Employee Name: RCUH Employee ID #:
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.
Medical Expense Reimbursement Account:
(Maximum annual contribution $2550 = $106.25 / pay period)
Dependent Care Expense Account:
(Maximum annual contribution $5000 = $208.33 / pay period)
PRETAX Transportation Benefits
IMPORTANT: PRIOR to electing, changing, or cancelling this coverage, read RCUH policy 3.530 RCUH Flexible Spending Plan. These
elections will remain in effect and continue automatically until the RCUH HR Department is notified of your wish to terminate or
alter your transportation program elections. Select an option and indicate your election(s) below:
Parking Expense Reimbursement
☐ Enrollment $ / Month
(Maximum Limit Per Month: $250.00 / month)
☐ Change $ / Month
☐ Cancel: Parking Expense Reimbursement
Transit Expense Reimbursement
Deduction occurs the month prior to coverage therefore your
election form must be received at least 30 days in advance.
☐ Enrollment $ / Month
(Maximum Limit Per Month: $130.00 / 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.
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) Internal Revenue
Service Code 125 for Pre-Tax Flexible Spending Accounts and/or (2) Internal Revenue Service Code 132 for Pre-Tax Transportation Accounts and will comply accordingly.
I understand that I must follow and comply with RCUH’s policy on Flexible Spending Accounts and the applicable plan document pursuant to the Flexible Spending Account
type.
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 once these elections are made, I cannot change them during the plan year, except as permitted by the Plan in accordance with Internal Revenue Service
regulations.
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.
I understand that I will have ninety (90) days to submit reimbursement requests for expenses incurred while I was still a participant of the plan for any money remaining in
my flexible spending account(s) at the end of the plan year or at the time I terminate participation in the plan. If after the ninety (90) days, the reimbursement forms and
applicable supporting documentation are not submitted to the insurance carrier, I will forfeit all rights to that money and the money shall remain the property of the RCUH.
Employee Signature: Date:
Choose Applicable Family Status Change Event.
