Flexible Spending Accounts (Optional)
Election/Change Form for CHEIBA Trust
Note: You must re-enroll in this plan each year

Employee Name





Last (print)
First
Initial
SS #

Home Address




/ /
Street
City
State
Zip
Birth Date




Home Phone
Work Phone
College/Agency





Email Address:

PURPOSE: This agreement is designed to allow an employee to convert a portion of his/her taxable earnings to a tax-free benefit status, pursuant
to a Code Section 125 plan and other codes listed under a Flexible Benefit Plan. Employees wishing to enroll a tax qualified domestic partner and
tax qualified dependents of a domestic partner must complete a, “Certification of Tax Qualified Dependents,” form to be eligible for plan participation.
AGREEMENT: The employer and employee mutually agree to this election. It is a binding agreement effective _____________ through
___________. No election changes are allowed unless an eligible status change or approved Family and Medical Leave Act change occurs.

LIMITATIONS: Termination of employment with this employer terminates this agreement. Only expenses not reimbursed to the employee by any
other insurance plan or company plan may be considered qualified expenses under the Flexible Benefit Plan.

I understand the benefit options available to me and choose the election(s) checked below.

I elect to reduce my gross wage and redirect the following dollars into the appropriate spending account(s) below:


a. * Health care expenses. If you are paid 9 pay checks (January – May and September – December) health care

expenses $ ___________________________ x 9 pay periods = $ _________________ per plan year ($2,550 Maximum)

b. Health care expenses. If you are paid 12 pay checks (January– December) health care expenses

$ ___________________________ x 12 pay periods = $ _________________ per plan year ($2,550 Maximum)




c. ** Dependent care expenses. If you are paid 9 pay checks (January – May and September – December) dependent
care expenses $ ___________________________ x 9 pay periods = $ _________________ per plan year ($5,000 Maximum)

d. Dependent care expenses If you are paid 12 pay checks (January– December) dependent care expenses

$ ___________________________ x 12 pay periods = $ _________________ per plan year ($5,000 Maximum)


List all dependents and spouse/ tax qualified domestic partner (must be completed)

Name
Date of Birth
Relationship
1.
_____________________________________________________________________________________________________________
2.
_____________________________________________________________________________________________________________
3.
_____________________________________________________________________________________________________________
4.
_____________________________________________________________________________________________________________
I understand that if I cannot reclaim this benefit compensation by the close of the plan year because I did not incur eligible expenses while I was
active in the plan, I then forfeit all remaining dollars. I also understand that my future PERA or DCPP benefits may be reduced by my participation
in this plan and that all dollars elected through this plan cannot be applied as a credit or deduction on my tax return.
Employee’s Signature X _______________________________________________
Date _________/__________/_________
** Complete the child and dependent care questionnaire if you plan to use the dependent care spending account.


Child and Dependent Care Questionnaire

1) Does the child/dependent live in your home at least 8 hours each day?
Yes 
No 
If yes, expenses are eligible for this plan.
2) Is your spouse/tax qualified domestic partner disabled?
Yes 
No 
If yes to either #2 or #3, eligible expenses
are limited to a maximum of $3,000 per year
Is your spouse/tax qualified domestic partner a full-time student 5
3)
Yes 
No 
for one child/dependent or $6,000 per year
months or more a year?
for two or more children/dependents




(maximum Federal tax credit). CHEIBA
4) Spouse's/Tax qualified domestic partner’s employer: _______________________*
Trust maximum is $5,000 per year


(* Eligible expenses are limited to the income of the lesser earning spouse/partner.)



I understand that I cannot pay my spouse/tax qualified domestic partner or other dependent for the care of my children or dependents and that my
reimbursed expenses are limited to the income of the lesser earning spouse.
For Internal Use Only - New Elections During Plan Year
Reason for Election
 New Hire
 Status Change
 Termination
COBRA for Health FSA
 Yes

No
Eligibility Date: ___________________________________________ First payroll deduction date: ____________________________________