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P.O. Box 71107 Oakland, CA 94612 1.800.617.4729 1.888.410.7361 www.sterlingadministration.com FSA ENROLLMENT FORM EMPLOYEE INFORMATION (PLEASE PRINT CLEARLY) Employee s First Name: M.I. Last Name:
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How to fill out fsa enrollment form
How to fill out FSA enrollment form:
01
Gather your personal information such as your full name, date of birth, and social security number.
02
Provide your contact information including your address, phone number, and email address.
03
Indicate the coverage period for which you are enrolling in the FSA, such as the calendar year or specific dates.
04
Specify the type of FSA you are enrolling in, such as a healthcare FSA or dependent care FSA.
05
Estimate the amount of money you plan to contribute to the FSA for the coverage period.
06
Review any eligibility requirements or restrictions that may apply, such as maximum contribution limits.
07
Sign and date the enrollment form to indicate your agreement and understanding of the terms.
Who needs FSA enrollment form:
01
Employees who have access to a Flexible Spending Account (FSA) benefit through their employer may need to fill out an FSA enrollment form.
02
Individuals who want to set aside pre-tax money to cover eligible expenses like healthcare costs or dependent care expenses can benefit from an FSA.
03
Those who want to take advantage of tax savings by contributing pre-tax income towards qualifying expenses may need to complete an FSA enrollment form.
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