Section 125 Flexible Benefits Enrollment Form

Bloomfield Board of Education

Section 125 Flexible Benefits Enrollment Form

July 1, 2017 – June 30, 2018

Participant Information (Required)

Name ______Last 4 Social Security # ______

(Print or type: Last, First, Middle Initial)

Mailing Address ______

City, State, Zip ______

Email Address ______Daytime Phone ______

Date of Birth ______Date of Hire ______

______

Direct Deposit

I authorize WageWorks to deposit my full reimbursement into my:

____ Checking Account or ____ Savings Account (please choose one)

Routing/Transit Number: ______Account Number: ______

Bank Name: ______

Spending Accounts

Annual Spending Account Elections for Plan Year: I request the following amounts be deducted from my pay with pretax dollars.
Health Care Spending Account($2,500 maximum) / $______per year / Dependent Day Care Spending Account
($5,000 per family or $2,500 for married employee filing separate tax returns.) / $______per year

Spending Agreement

The amount(s) I have elected will be taken from my pay in equal installments on a pretax basis. I understand that if I fail to submit eligible claims for entire amount elected, I forfeit any remaining balance. The election(s) will continue throughout the Plan Year or until I notify the company in writing of a qualifying Status Change. If I do not use all the money in my account(s) during my dates of participation, I understand that any balance will be forfeited. If I have provided an email address, I am requesting that all possible communications be sent through email.

Employee Signature ______Date:______

Employer’s use only

/ Effective Date ______/ Per Pay Period Amount: ______1st Payroll Deduction Date: ______

125.6001.4