Get the free FSA Enrollment/Change Form

This document is used by employees to enroll in or make changes to their Flexible Spending Account (FSA) benefits, including personal information and election details.

How to fill out fsa enrollmentchange form

How to fill out FSA Enrollment/Change Form

1. Obtain the FSA Enrollment/Change Form from your employer or the benefits portal.
2. Read the instructions carefully to understand what information is required.
3. Fill in your personal identification details such as name, address, and social security number.
4. Select the type of Flexible Spending Account (FSA) you want to enroll in or make a change to (e.g., healthcare or dependent care).
5. Indicate the amount you wish to contribute for the plan year, ensuring it does not exceed the annual limit.
6. Fill out any relevant information regarding dependents if applicable.
7. Review your selections to make sure all information is accurate and complete.
8. Sign and date the form to certify the information provided.
9. Submit the completed form to your HR department or designated benefits administrator by the deadline.

Who needs FSA Enrollment/Change Form?

1. Employees who wish to enroll in a Flexible Spending Account (FSA) for the first time.
2. Employees who need to make changes to their existing FSA elections, such as contribution amounts or dependent coverage.
3. New hires who need to set up their FSA during the onboarding process.
4. Employees who experience qualifying life events that allow them to change their FSA elections.

People Also Ask about

What is the meaning of FSA?

A flexible spending account (FSA) is known as a kind of savings account that gives the account holder specific tax advantages.

Are FSA transferable?

You typically can't take your FSA with you if you switch jobs or leave the workforce. Generally, if you leave your job, any remaining funds in your FSA will go back to your employer. This is also the case if you don't spend all your FSA dollars within the plan year.

What is the phone number for NYC FSA?

As always, you can speak with a Customer Service Representative about the program and your account(s) on the phone by calling at (212) 306-7789.

Can you make changes to your FSA?

You can only make changes that are “consistent" with the qualifying event (i.e. coverage eligibility must somehow be affected). You should always check in with your FSA provider about qualifying events. Your Summary Plan Description should list which qualifying events allow you to make changes under your plan.

For pdfFiller’s FAQs

What is FSA Enrollment/Change Form?

The FSA Enrollment/Change Form is a document used by employees to enroll in or make changes to their Flexible Spending Accounts (FSAs), allowing them to use pre-tax dollars for eligible medical and dependent care expenses.

Who is required to file FSA Enrollment/Change Form?

Employees who wish to enroll, change their existing contributions, or opt out of their FSA must file the FSA Enrollment/Change Form during open enrollment periods or after a qualifying life event.

How to fill out FSA Enrollment/Change Form?

To fill out the form, employees should provide their personal information, including name and employee ID, specify the type of FSA they wish to enroll in or change, and indicate the amount of money they wish to set aside for the FSA.

What is the purpose of FSA Enrollment/Change Form?

The purpose of the FSA Enrollment/Change Form is to facilitate the enrollment process of employees into FSAs and to manage any changes to their participation or contribution amounts, ensuring they take advantage of tax savings on eligible expenses.

What information must be reported on FSA Enrollment/Change Form?

The form typically requires personal details such as employee name, ID, and contact information, the type of FSA enrolling in (medical or dependent care), contribution amounts, and any changes to existing enrollments or contributions.