SRN
Sacramento Regional Transit District Flexible Spending Arrangement Enrollment Form
Plan Year: 01/01/2021-12/31/2021
Last Day to Submit Claims: 2/28/2022
Employee Information Please write legibly to ensure proper enrollment
Last Name, First Name
SSN / Employee ID #
Home Address (Street, City, State, Zip Code)
Date of Birth
Phone Number
Email Address
Effective Date
Benefit Elections
Section 125 Benefit
Annual Election
Paycheck
Deduction
Health Care FSA
Maximum of $2,750.00 per plan year
$___________
__
$_______
__
Day Care FSA
Maximum of $5,000.00 per plan year
(or $2,500 if you’re married and filing taxes separately)
$___________
__
$_______
__
Premium Conversion
The group insurance premiums you pay through your paycheck are automatically deducted pre-tax. Premium contributions
toward domestic partner coverage will be deducted post-tax unless they qualify as a tax dependent.
Automatic
Debit Card & Direct Deposit
Navia Debit Card You may use the card to pay for expenses directly from the funds in your Health Care
FSA. There is no cost for the initial card. The cards are valid for 3 year periods; if you’ve previously received
the card then it will be reloaded with your new election. You must provide a valid email address to use the
card.
Automatic
Direct Deposit Reimbursements are electronically deposited
into your bank account. If you’ve previously signed up for direct
deposit with Navia your information will remain on file and you
do not need to complete this section.
Yes
No
Checking
Savings
Account #:
Routing #:
Signature
This election form will remain in effect and cannot be revoked or changed during the plan year unless the revocation and new election are on account of and consistent
with federal regulations. I understand that Health FSA reimbursements will be available only for qualifying medical care expenses for myself, spouse, and dependents. I
also understand that Day Care reimbursements will be available only for qualifying day care expenses. I agree to notify the Employer if I have reason to believe that any
expense for which I have obtained reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Employer on demand for any liability it may
incur for failure to withhold federal, state or local income tax or Social Security tax from any reimbursement I receive of a non-qualifying expense, up to the amount of
additional tax actually owed by me. I understand the benefits and I have read the reverse page. I hereby authorize and direct my employer to reduce my salary by the
amount necessary to pay for the benefit(s) as shown above for the plan year indicated above.
YES, the above benefits have been explained to me and I elect to participate as indicated
NO, the above benefits have been explained to me and I decline participation
Employee Signature
Date
X
Completed Enrollment Forms must be returned to Human Resources
Please see the reverse side for important information regarding the above benefits
click to sign
signature
click to edit
Additional Information
Premium Conversion
If the enrollment status is marked as ‘AUTOMATIC’, you must notify your employer in writing to decline enrollment in this benefit. Premium Conversion is
subject to the change in status rules and is considered an election equal to the amount of your premium deductions.
Health Care Flexible Spending Arrangement (“Health Care FSA”)
Reimbursement will only be available for qualifying medical care expenses as set forth in the Plan Document and Section 213 of the Internal Revenue Code. It
is your responsibility to check the eligibility of an expense prior to enrollment.
Group Medical Plan Premiums cannot be reimbursed through the Health Care FSA and will be deducted pre-tax through the Premium Conversion Plan.
Therefore, do not include the cost of premiums in your FSA annual election amount.
Day Care Flexible Spending Arrangement (“Day Care FSA”)
Reimbursement will be available only for qualifying day care expenses as described in the Internal Revenue Code Section 129, the Plan document and the
Summary Plan Description.
Participation in a Day Care FSA will require you to complete tax form 2441 when filing federal taxes. If your plan includes a Grace Period any amounts carried
forward or forfeited during a taxable year should be entered in Line 13 of Form 2441. If you or your spouse is a full-time student, please consult IRS Publication
503.
If the Plan Year is less than twelve (12) months, the plan limit may be prorated to be less than the $5,000 calendar year limit mandated by the IRS.
Use-It or Lose-It
You must claim all elected funds by the end of the run-out period. Money left in the plan after the end of the run-out period cannot be refunded to you; this is
referred to as the Use-it or Lose-it rule. You must claim all elected funds by the end of the run-out period. After the run-out period is complete, unused Day Care
FSA balances will be forfeited; this is referred to as the Use-it or Lose-it rule. Unused Health Care FSA balances above $50 up to $550 will be rolled over to the
subsequent plan year. Any Health Care FSA funds below $50 or in excess of $550 will be forfeited.
Claim Runout Period
The claim runout period allows you to submit claims after the end of the plan year. Claims received after this period will be denied.
Lost Checks and Reissues
Lost or stale dated FSA checks can be reissued 10 business days after the original check date. There is a $25.00 check reissue fee. The check reissue request
will require at least one business day to process.
Any fees associated with presenting a canceled check will be deducted from your FSA as well as the face value of the check.
Direct Deposit
All electronic funds transfers (EFT) will be initiated on the same day as the normal check reimbursement date. Deposits may take up to two (2) business days to
appear in the designated account.
Returned items due to incorrect banking information will be assessed a $10.00 fee that will be deducted from your FSA balance.
Deductions
FSA deductions will be deducted from your paycheck evenly throughout the plan year. You must indicate an annual election and a per paycheck deduction on
your enrollment form. If you enroll in the plan after open enrollment then please divide your annual election by the remaining deductions in the plan year.
Change in Status
All elections set forth are considered irrevocable for the entire plan year unless there is a qualifying change in status. Please consult the plan document or
summary plan description for a list of qualifying events.
In the event of a change in status the change in election must be necessitated by and consistent with the change in status and the change must be acceptable
under IRS Regulations.
Eligibility
Independent contractors and self-employed individuals are not eligible to participate in the Plan. Self-employed individuals include: Sole Proprietors of their own
business; General Partners in a general partnership and General Partners in a limited partnership; Limited Partners of partnerships with guaranteed payments;
more than 2% Shareholders of an S corporation as well as the spouse, children, parents and grandparents of a more than 2% Shareholder; and non-employee
Members of an LLC. It is your responsibility to determine your eligibility.
Expenses must be incurred during the plan year and while you are an active participant in the plan. Any expense incurred prior to your effective date or after
your termination date cannot be reimbursed.
Debit Card
If you elect to use the card please keep in mind that you may still need to submit supporting documentation to verify that a charge is eligible. You will be notified
via email if you have a charge that requires documentation. You can check your account online to view any outstanding charges or contact customer service.
If you use the card for an ineligible expense or do not substantiate a charge within 75 days of receiving the first request for substantiation your card may be
temporarily suspended to prevent further use. The IRS provides the participant with 2 methods for correcting an ineligible or unsubstantiated charge: a) repay
the plan for the amount of the expense, or b) request the substitution or offset of future out of pocket expenses. If neither option “a” nor “b” is successful the final
option illustrated by the IRS permits the employer to deduct the ineligible expense from the participant’s wages or other compensation consistent with federal
and state law.
Electronic Disclosure Notice
By providing your email address you consent to receive email communications from Navia, agents, and subcontractors regarding the Plan.
If you no longer wish to receive information electronically, you may withdraw consent at any time at no cost. To withdraw consent, please contact Navia.
You have a right to receive a paper version of an electronically furnished document at no cost.
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