For Human Resources’ Use:Effective Date: , 2016
New Hire Status Change Open Enrollment Termination Address Change Name Change
Highmark enrollment completed: (date) Banner data entry completed:(date)
Franklin & Marshall Flexible Spending Accounts Enrollment Form
Please complete all sections, sign, and return to Human Resources, CSQ, P.O. Box 3003,
Lancaster, PA 17604-3003.
Employee’s Name:Social Security #:
First Middle Last
Home Address:Department:
Street City State Zip code
Employee’s Gender: Male FemaleYou Are Paid: Monthly (faculty) or Bi-weekly (staff)
Employee’s Date of Birth: ____/____/____ Your Marital Status: Married Single College ID #:
A. Your Flexible Spending Accounts Election for 2016:
Medical Expense Reimbursement Account Tax-Exempt Contribution(salary reduction)
Maximum annual contribution: $2,550
$______per pay (26 pays per year for professional staff, 12 pays per year for faculty)
Opt-out / I elect not to participate in the Medical Expense Reimbursement Account
Dollars remaining in your Medical Expense Reimbursement Account as of March 15 of the following calendar year will be forfeited in accordance with IRS regulations and Plan documents. You may not make changes to your elections during the calendar year unless you experience a relevant status change and provide timely notice to Human Resources. Contributions will be deducted in equal amounts from each paycheck. Your elections will not automatically carry over to the next calendar year.
Dependent Care Account Tax-Exempt Contribution(salary reduction)
Maximum annual contribution: $5,000, or $2,500 if married and filing separate tax returns
$______per pay (26 pays per year for professional staff, 12 pays per year for faculty)
Opt-out / I elect not to participate in the Dependent Care Account (please skip to section C)
The amount you contribute to the Dependent Care Account may not exceed the lesser of: $5,000; your annual salary; if married, your spouse’s annual salary. If your spouse is a full-time student or is incapable of self-care, his/her income is assumed to be $3,000 per year if you have one person for whom you incur eligible dependent care expenses, or $6,000 per year if you have two or more persons for whom you incur eligible dependent care expenses. Your contribution may not exceed $2,550 if married and filing separate tax returns. Your combined maximum contribution to a Dependent Care Account may not exceed $5,000 per year if your spouse also participates in a Dependent Care Account through his/her employer and you file a joint federal tax return.
Dollars remaining in your Dependent Care Account at the end of the calendar year (December 31) will be forfeited in accordance with IRS regulations and Plan documents. You may not make changes to your elections during the calendar year unless you experience a relevant status change and provide timely notice to Human Resources. Contributions will be deducted in equal amounts from each paycheck. Your elections will not automatically carry over to the next calendar year.
B. Eligible Dependents (Must be completed if you plan to submit claims for your dependents’ expenses. Include only those dependents for which you plan to submit claims for reimbursement – please see below for the definition of eligible dependents.):
In order to enroll dependents you must submit proof of dependent status, for each covered dependent, to Human Resources.
Spouse:
First & last name GenderDate of birth
Child:
First & last name GenderDate of birth
Child:
First & last name GenderDate of birth
Other Eligible Relative:
First & last name GenderDate of birth
C. Employee Authorization(please read and sign below):
I understand that prior to the beginning of each Plan Year, I can choose to participate in the College’s Flexible Spending Accounts Plan by electing benefit(s), or I can elect to waive all before-tax benefits. I am aware that this enrollment does not enroll me in or guarantee coverage under the Health Insurance & Prescription Drug Plan because its coverage is provided under a separate plan that contains its own distinct requirements. If I elect to participate in the Medical Expense Reimbursement Account, a before-tax account will be established from which I will be reimbursed for Qualifying Medical Care Expenses up to the annual limit (disclosed by the College). I understand that if I elect to participate in the Dependent Care Account, a before-tax account will be established from which I will be reimbursed for Qualifying Dependent Care Expenses up to the annual limit (disclosed by the College). If I elect Flexible Spending Accounts coverage, I understand and agree that amounts remaining in my account(s) after expenses are reimbursed per the Plan documents will be forfeited by me. Furthermore, I understand and agree that claims cannot be reimbursed if they are incurred after my regular coverage terminates. I understand my Flexible Spending Accounts elections will not automatically carry over from year-to-year. To participate, I must submit this form during the annual Open Enrollment period. I authorize the College to reduce my salary by the contribution(s) I have elected above. I understand this amount will be applied, according to my elections, to the Flexible Spending Accounts Plan. Contributions will be deducted from my gross pay on a before-tax basis, in equal installments on regular pay dates. I understand a before-tax contribution will reduce my Social Security wages that are used in calculating Social Security benefits, and I may experience a reduction in my Social Security benefits. I understand I can only begin, change, or terminate participation and elections during the annual Open Enrollment period unless a dependent or Iexperience a relevant status change. I agree to notify Human Resources within 31 calendar days of any change in status. I declare that the above information is correct and, to the best of my knowledge, any dependent(s) listed above is an eligible dependent under the Plan. I understand that, through the Insurance Premium Payment Plan, my health plan and dental plan premiums, if applicable, will be deducted from my pay on a before-tax basis unless I notify Human Resources, in writing, that I elect to pay such premiums on an after-tax basis.
For Dependent Care Account participants:I declare that my Dependent Care Account election does not exceed the maximum allowable election. If married, I confirm that my spouse is currently:
a)employed outside the home, and
my spouse’s annual salary is currently greater than the annual Dependent Care Account contribution I have elected for the coming calendar year
OR
b)my spouse is not employed outside the home, and
my spouse is a full-time student, or
my spouse isincapacitated and unable to provide care for my dependents(s).
Franklin & Marshall agrees to reduce your salary each pay period and to provide to you those benefits for which you are entitled under the Plan. Franklin & Marshall retains the right to adjust or terminate your salary reduction election, if necessary, to ensure the Plan complies with the Internal Revenue Code.
Employee’s Signature:______Date:______
For purposes of the Medical Expense Reimbursement Account, the following are eligible dependents:
- The legally recognized spouse of an employee, including a same-sex spouse recognized under federal law.
- Your (the employee's) child, if the child is age 25 or younger (under age 26).
- Your child, grandchild, sibling or stepsibling, parent, grandparent, aunt, uncle, niece, or nephew who is physically or mentally incapable of caring for him/herself and depends on you (the employee) for at least half of his/her financial support.
- An individual who is physically or mentally incapable of caring for him/herself; depends on you (the employee) for at least half of his/her support; and is a member of the employee's household for the entire taxable year.
For purposes of the Dependent Care Account, the following are eligible dependents if you claim them as dependents on
your federal tax return:
- Your (the employee's) child or stepchild, if the child is age 12 or younger (under age 13); if the child does not provide over half of his/her own support during the calendar year; and if the child shares your (the employee’s) principal residence for more than 6 months of the calendar year.
- The spouse, including a same-sex spouse recognized under federal law, of the employee who is physically or mentally incapable of caring for him/herself; lives in your (the employee’s) household for more than one-half of the taxable year; and spends at least 8 hours per day in the employee’s home.
- Your child, grandchild, sibling, parent, grandparent, aunt, uncle, niece, or nephew who is physically or mentally incapable of caring for him/herself and depends on you (the employee) for at least half of his/her financial support; lives in your (the employee’s) household for more than one-half of the taxable year; and spends at least 8 hours per day in the employee’s home.
- An individual who is physically or mentally incapable of caring for him/herself; depends on you (the employee) for at least half of his/her support; lives in your (the employee’s) household for more than one-half of the taxable year; and spends at least 8 hours per day in the employee’s home.
If a child receives over one-half of his/her support during the year from his/her parents who are separated, divorced, or have
lived apart for the last 6 months of the year, and was in the custody of one or both parents during more than one-half of the
year, the child will be an eligible dependent under this Plan even if the child did not live with the employee for more than one-
half of the year, if: (a) there is a written agreement that allows this, or (b) the custodial parent agrees that he/she will not claim
the child as a dependent.
Expenses eligible for reimbursement are those incurred to care for an eligible dependent and to enable you (the employee) to remain gainfully employed.
The term "child" is defined as an individual who is the son, daughter, stepson, or stepdaughter of the employee; includes both a
legally adopted child of the employee and a child who is lawfully placed with the employee for legal adoption; and includes an
“eligible foster child”, defined as an individual who is placed with the employee by an authorized placement agency or by
judgment, decree, or other order of any court of competent jurisdiction.
The Plan Administrator reserves the right to require verification of dependent status (such as a copy
of the most recent tax return listing dependents, marriage and/or birth certificate, or a copy of a
court order) before approving coverage for a dependent.
Rev. 11/2015