Flexible Spending Account Enrollment Form
Step 1: Participant Information
*=Required Fields
*Employer Name (Do not abbreviate) *Department
*Participant Name (First, MI, Last) *Social Security Number
*Participant Mailing Address Email Address (If provided, all notifications will be sent via email)
*City *State *Zip
Day Telephone *Birth Date (mm/dd/yyyy) *Hire Date (mm/dd/yyyy)
Other _______________
*Payroll Cycle Date of first payroll withholding
Step 2: Spouse and Dependent Information
*Name (Last, First) *Date of Birth *Social Security Number
Step 3: Election
Account Type Election Amount
Minimum Reimbursement amount for manual check is $25
Step 4: Authorization or Refusal
I hereby elect the benefits indicated above. I have read and understand the enrollment materials (flex brochure, enrollment form, daycare form, direct deposit form and claim
form) and I authorize my employer to adjust my pay as required by my election. I understand that this election is binding and cannot be revoked or modified until the next plan
year, except under the limited circumstances that are described in detail in the SPD that I have received from my employer (i.e. marriage, divorce, birth). I understand that if I
am enrolled in a Health Savings Account (HSA) that I cannot enroll in the Medical FSA, and that I can only enroll in the Limited Purpose FSA if my employer offers this
SIGNATURE OF PARTICIPANT_______________________________________________________________ DATE _____________________
Step 5: Employer Authorization
Benefit Effective Date Date of first payroll withholding
SIGNATURE OF EMPLOYER_______________________________________________________________ DATE _____________________
Medical Expense Account
_______ Annually
Dependent Care Reimbursement
_______ Annually