Flexible Spending Account
Benefit Election Form for the 2007 Plan Year

Bay de Noc Community College

 

___  Enrollment or Re-Enrollment     

___ Change of Personal Information

___  Change in Family Status          

___ Termination of Employment

 

Personal Information

Employer:  Bay de Noc Community College                      

 

Department:_________________________________ Hourly ___   Salaried ___

 

 

Last Name: ___________________________    First Name:_________________________  M.I.: ______

Address:________________________________________________________________________________

City: ___________________________________     State:_____      Zip:_______________

 

Email Address: __________________________________                  Date of Birth: __________________

 

List of Dependents to be Covered         

** A charge of $5.00 will be assessed per each dependent card (Debited out of your Flex Account)

Relationship

Last Name

First Name

Gender

SSN

Birth Date

Extra Card Y/N **

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   Enter Per Pay Amount

Number of Pays

    Annual Election

 

1. Medical/Dental Spending Account      

1. $ _______________   X

_______________  = 

$ _______________

 

2. Dependent Day Care Spending Account    

2. $ _______________   X

_______________  = 

$ _______________

 

 

(Dependent Care Maximum $ 5,000 annually or $2,500 annually for married individuals filing a separate return.  Medical/Dental Spending Account Maximum $ 4,000 annually.)

 

I hereby apply for the options listed above. I authorize my employer to adjust my pay as required by my election. I understand that the benefit options I have elected will remain in effect throughout the plan year, unless I have a change in family status. I also understand that any unspent money remaining in my account(s) at the end of the plan year will be forfeited.

 

I agree that if my employer pays out of FlexSave Spending Accounts, whether by inadvertence or design, more than I was entitled to receive, my employer may withhold amounts from my wages until the improperly paid a out has been recovered. My submission of this form authorizes my employer to reduce my compensation to recover amounts improperly paid from my Health Care Account.

 

Date: ____________________           Signature: _____________________________________________
 
 


 

 

 

Please also complete the Flexible Benefit Plan-Payroll Reduction Agreement and submit to Tina Doucette in Human Resources.  Thank you.

 

I:HR/benefits/Flex125