Get the free FSA Status Change Form - Henrico County Public Schools

FLEXIBLE SPENDING ARRANGEMENT EMPLOYEE CHANGE IN STATUS FORM Section I Employee Information Last Name, First Name Employee SSN Company Code HPS Address Change DOB St Zip City Email Day Phone EFFECTIVE

How to fill out fsa status change form

Instructions for filling out the FSA status change form:

1. Obtain the FSA status change form from your employer or insurance provider.
2. Read the instructions carefully to understand the purpose and requirements of the form.
3. Provide your personal information including your name, address, and contact details in the designated fields.
4. Specify the type of status change you are requesting (e.g., change in marital status, birth/adoption of a child, change in employment status).
5. Attach any necessary documentation to support your status change request, such as marriage certificates or birth certificates.
6. Indicate the effective date of the requested status change.
7. If you are adding dependents to your FSA, provide their names and relationship to you.
8. If you are removing dependents from your FSA, provide their names and the reason for their removal.
9. If you are changing your employment status, indicate the reason for the change (e.g., termination, resignation, retirement).
10. Review all the information provided on the form for accuracy and completeness.
11. Sign and date the form to certify that the information provided is true and accurate to the best of your knowledge.
12. Submit the completed form to the designated department or individual within your organization or insurance provider.

Who needs the FSA status change form?

1. Employees who experience a change in their marital status such as marriage or divorce.
2. Employees who have a child through birth or adoption.
3. Individuals who experience a change in employment status, such as termination or retirement.
4. Employees who need to add or remove dependents from their FSA coverage.
5. Any FSA participant who needs to update their personal information, such as address or contact details.
6. Individuals who want to modify their FSA contribution based on a change in their healthcare needs or expenses.

Note: The specific requirements for the FSA status change form may vary depending on your employer or insurance provider. It is recommended to consult the provided instructions or reach out to the relevant department for any clarification.

For pdfFiller’s FAQs

What is fsa status change form?

The FSA status change form is a document used to report any changes in the status of a flexible spending account (FSA).

Who is required to file fsa status change form?

Employees who have a flexible spending account (FSA) are required to file the FSA status change form if there are any changes in their account status.

How to fill out fsa status change form?

To fill out the FSA status change form, the employee must provide their personal information, details of the status change, and any supporting documentation.

What is the purpose of fsa status change form?

The purpose of the FSA status change form is to inform the employer or FSA administrator about any changes in the account status.

What information must be reported on fsa status change form?

The FSA status change form must include the employee's name, FSA account number, details of the status change, and any supporting documentation.

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