FSA Enrollment 1Employee Information2Benefit Elections3Additional Card Holders4Direct Deposit Info5Election Information Employee InformationName* First Last Social Security Number* Date of Birth* MM slash DD slash YYYY Date of Hire* MM slash DD slash YYYY Employee Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone* Benefit ElectionsGroup Insurance Premiums — If you participate in your employer’s insurance plan(s), your premiums will automatically be deducted on a pre-tax basis unless you notify your Human Resource or Personnel Department. Flexible Spending Accounts — The IRS regulations state four conditions: 1) Any expenses you incur must be within the plan year; 2) Any expenses you incur must not be covered by any other source, such as insurance; 3) You must provide proper documentation to receive payment; 4) You cannot change or revoke your elections during the plan year unless there is a specific change in status and your employer allows such changes.Medical Flexible Spending Amount*(Annual Amount)Dependent Care Account*(Annual Amount)*By participating in a Flexible Spending Account you will receive a Benefits Card. By using the benefits card, you certify that each time the card is used, it will be used only for Qualified purchases as described in the cardholder agreement, and you have not received or will not see reimbursement for any expenses paid with the card from any other benefit source. This card may not be used at all merchants that accept Visa debit Cards. Additional Benefits Card Holder RequestList Name & DOB (click plus symbol to add additional names)First NameM.I.Last NameDOB Direct Deposit Information / Bank Account Information (NOT REQUIRED)I authorize Consolidated Admin Services to initiate a credit and/or debit entry to my account for my plan reimbursements. This agreement is to remain in full effect until written notification is supplied by me to CAS terminating this agreement. A voided check must accompany enrollment form. Do not use a deposit slip as the number could be available.Bank Name Account Number Routing Number Election InformationPlease select option:* Yes, I wish to participate in the flexible spending account plan and authorize payroll reduction from my salary on a pre-tax basis in the amount(s) indicated below, and continuing until this election is amended or terminated or until the Plan Year ends. Employer-sponsored benefit coverage contributions are automatically reduced from my compensation on a pre-tax basis. No, I have been offered the opportunity to enroll in the flexible spending account plan and do not wish to enroll at this time. However, my employer-sponsored benefit coverage contributions are automatically reduced from my compensation on a pre-tax basis. Type Signature* Today's Date* MM slash DD slash YYYY
