Flexible Spending Account Enrollment

Plan Effective Date = 1 January 2024

HSA vs FSA INFO

A Health Savings Account (HSA) is an account that is only available to members who are enrolled in a High Deductible Health Plan.

A Flexible Spending Account (FSA) is a benefit that allows you to set aside money on a pre-tax basis for certain health and dependent care expenses.

Are you currently enrolled in a Health Savings Account? (HSA)

YesNo

Since you are enrolled in an HSA account you are not eligible for the traditional Flexible Spending Account because you have a Health Savings Account. You can participate in a Limited Purpose Flexible Savings Account but it will ONLY be usable for dental and vision expenses.

What is your annual election (amount you will spend) on dental and vision?

If you send your child(ren) to day care how much do you spend annually on day care expenses

Note* - Annual FSA Maximum for 2024 is $3,200*

	Annually
1. What is your annual election for medical, dental and vision?
2. How much do you spend on child day care expense annually? (if none, then put "0" in the field to the right)

Total

Employee's Name*

Employee's SSN:*

Employee's Address*

Employee's City*

Employee's State*

Employee's Zip Code*

Employee's Email Address*

Date*

Date

Employee's Signature*

No change or revocation of this Participation Agreement can be made at any time during the plan year unless there is a change in family status (including marriage, divorce, death of a spouse or child, birth or adoption of a child, termination of spouse’s employment and such other events as the administrator determines will permit a change or revocation). The employee agrees on demand to indemnify and reimburse the employer for any liability that may incur from failure to withhold federal and state income tax or social security tax.

I have read the explanation of the Flexible Spending Account program and understand my benefit choices. I authorize the selections I have made as well as the payments required for those selections. I understand the following:

· The above selections are effective for the entire year unless I experience a recognized change in status.

· Any money placed into either the Health Care or Dependent Care Spending Accounts and not used by the end of the plan year will be forfeited.

· The amount I have elected to contribute to the Dependent Care Account cannot exceed the amount of my or my spouse’s income, whichever is less.

· The Health Care Spending Account is a benefit subject to COBRA if my employment is terminated.

· If my annual reimbursements exceed my annual election in error, I agree to reimburse the plan.

1. Reimbursements will be available only for "qualifying medical care expenses" for yourself, your spouse and dependents (including children up to age 26). Generally, "qualifying medical care expenses" are those medical, dental and/or vision expenses normally deductible on my federal income tax return (without regard to the percentage of adjusted gross income limitation) or otherwise allowed by law. 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 nonqualifying expense, up to the amount of additional tax actually owed by me.

· Claims must be submitted within 90 days after the end of the Plan Year.

· If you terminate employment, claims must be submitted within 30 days after the date of your termination, subject to the conditions below.

· This section of the agreement will automatically terminate if the Plan is terminated or discontinued. I will, however, be entitled to be reimbursed for eligible expenses (to the extent funded) for the remainder of the Plan Year.

· If I cease my employment with the Employer, my participation in the Health Flexible Spending Account will be subject to the continuation coverage rules of COBRA.

· I cannot seek reimbursement from this account for a medical expense which I intend on taking as a deduction or credit on my tax return. I elect to participate in the Dependent Care Flexible Spending Account for the Plan Year

2. Reimbursement will be available only for "qualifying dependent care expenses" as described in the Internal Revenue Code Section 129, the Plan document and the Summary Plan Description. 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 nonqualifying expense, up to the amount of additional tax actually owed by me.

· I agree to provide the Administrator with a statement from the service provider that includes the amount of the expense as proof that the expense has been incurred.

· I agree to provide the Administrator with the name, address, and if applicable, the taxpayer identification number of the service provider.

· This section of the agreement will automatically terminate if the Plan is terminated or discontinued. I will, however, be entitled to be reimbursed for eligible expenses (to the extent funded) for the remainder of the Plan Year.

· I will only be reimbursed for amounts up to the balance in my account at the time of my request.

· I cannot claim a dependent care tax credit on amounts I receive as reimbursements under this Dependent Care Flexible Spending Account.

· Claims must be submitted within 90 days after the end of the Plan Year.

· If you terminate employment, claims must be submitted within 30 days after the date of your termination.