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This form is used by employees to enroll in the Medical and Dependent Care Flexible Spending Accounts offered by the University of Dayton, detailing salary reductions and contribution limits.

How to fill out medical flexible spending account

How to fill out Medical Flexible Spending Account and Dependent Care Flexible Spending Account Enrollment Form

1. Obtain the Medical Flexible Spending Account (FSA) and Dependent Care FSA Enrollment Form from your employer's HR department or online portal.
2. Read the instructions carefully to understand the eligibility and benefits of both accounts.
3. Fill in your personal information including name, address, Social Security number, and any other required identification details.
4. Indicate your desired contribution amounts for both the Medical FSA and Dependent Care FSA for the upcoming plan year.
5. Provide details about your dependents for the Dependent Care FSA, including their names, dates of birth, and Social Security numbers.
6. Sign and date the form to certify that the information is complete and accurate.
7. Submit the completed form to your HR department by the specified deadline.

Who needs Medical Flexible Spending Account and Dependent Care Flexible Spending Account Enrollment Form?

1. Employees who want to set aside pre-tax dollars for qualified medical expenses through the Medical FSA.
2. Parents or guardians who incur dependent care expenses for eligible dependents while they work or look for work.

For pdfFiller’s FAQs

What is Medical Flexible Spending Account and Dependent Care Flexible Spending Account Enrollment Form?

The Medical Flexible Spending Account (FSA) and Dependent Care Flexible Spending Account Enrollment Form is a document that allows employees to enroll in these accounts which provide tax-advantaged savings for medical expenses and dependent care costs.

Who is required to file Medical Flexible Spending Account and Dependent Care Flexible Spending Account Enrollment Form?

Employees who wish to participate in the Medical Flexible Spending Account or Dependent Care Flexible Spending Account offered by their employer are required to file this enrollment form.

How to fill out Medical Flexible Spending Account and Dependent Care Flexible Spending Account Enrollment Form?

To fill out the form, employees need to provide personal information, indicate the amount they wish to contribute to each account, and specify their dependent information for the Dependent Care FSA.

What is the purpose of Medical Flexible Spending Account and Dependent Care Flexible Spending Account Enrollment Form?

The purpose of this form is to formally enroll employees into the respective accounts, enabling them to allocate pre-tax dollars for qualified medical and dependent care expenses, thereby reducing their taxable income.

What information must be reported on Medical Flexible Spending Account and Dependent Care Flexible Spending Account Enrollment Form?

The form must report personal identification details, the desired contribution amounts for both the Medical FSA and Dependent Care FSA, and information about eligible dependents for the dependent care expenses.