FSA Enrollment Form

First Name

Last Name

Street Address



Zip Code

Email Address

Date of Birth

What is your Annual Election Amount

Annual Election Amount must be between a maximum of <span>$</span>3,050 and a minimum of<span>$</span>240
(to determine your weekly deduction divide your annual amount by 48)
**You may be asked at a later date for direct deposit information

I agree that I am authorizing my employer to reduce my compensation by the amount specified. This election will expire at the end of the plan year and I must make a new election each year. - I am not permitted to change my FSA or DCA elections during the plan year unless the change is due to and in accordance with certain recognized IRS regulations for change in status events. -Any funds left in my FSA and/or DCA at the close of the plan year may be forfeited in accordance with the plan documents. -If I terminate employment, I have 90 days to turn in claims for dates of service that occurred prior to my termination. -My employer may reduce or cancel this election as necessary to comply with provisions of the Internal Revenue Code.

Please enter your full legal name

By typing my name in the box above, I understand that I am doing so in place of a written signature.

Please type your Full Name in the box below. By typing my name in this box, I acknowledge that I am using a typed signature in place of a written signature and that the information in this waiver pertains to me and is truthful and accurate to the best of my knowledge.

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