"Flexible Spending Account Enrollment Form" - Ohio

Flexible Spending Account Enrollment Form is a legal document that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio.

Form Details:

  • Released on October 15, 2020;
  • The latest edition currently provided by the Ohio Department of Administrative Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download "Flexible Spending Account Enrollment Form" - Ohio

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Flexible Spending Account
Department of
Enrollment Form
Administrative Services
Use this form to enroll in your Flexible Spending Accounts. Forms must be completed by October 30, 2020. Please complete
all entries on this form. Then print, sign, date this form, and submit the completed form to:
Postal:
Fax: 866-872-7047
ConnectYourCare
Want an easier way to enroll? Enroll online at
P.O. Box 622337
www.connectyourcare.com/stateofohio and skip the paper form!
Orlando, FL 32862-2337
STEP 1: Personal Information
First Name:
Last Name:
Plan Effective
Employee ID:
__ __ /__ __ /__ __ __ __
Date:
Permanent
City:
State:
Zip Code:
Address:
Date of Birth:
Email Address:
__ __ /__ __ /__ __ __ __
(Month/Day/Year)
Marital Status:
Enrollment
o Single o Married o Divorced
o New enrollment
o Re-enrollment
Status:
o Widowed
STEP 2: Health Care Spending Account Elections
(Select Limited Purpose Heath Care Spending Account, which is
limited to dental and vision expenses, if you are enrolled or plan to enroll in the HDHP with a Health Savings Account (HSA) plan.)
o Select Health Care Spending Account (HCSA)
o Select Limited Purpose Health Care Spending Account (LPSA)
I. Annual Employee Contribution
(Not to Exceed Contribution Maximums*)
*For 2021, Health Care Spending Account contributions are limited to a minimum of $240 and a maximum of $2,500 each year. The limit is per person; a
married couple may each contribute up to the specified limit.
STEP 3: Dependent Care Spending Account Elections
o Select Dependent Care Spending Account (DCSA)
I. Annual Employee Contribution
(Not to Exceed Contribution Maximums**)
**Couples who are married and file a joint return, as well as single parents, can contribute a minimum of $240 and up to $5,000 in a Dependent
Care Spending Account. Couples who are married and file separately can put a maximum of $2,500 each into a Dependent Care Spending Account.
STEP 4: Authorization and Certification
I understand that:
I hereby authorize my employer to reduce my gross salary before Medicare, local, state, and federal income taxes are calculated
by the total amount of annual salary deduction indicated above. This election will expire at the end of the calendar year, and I must
make a new election each year.
I am not permitted to change my elections during the calendar year unless the change is due to and in accordance with certain
recognized IRS regulations for change in status events and as allowed in the plan documents.
Funds left in my Dependent Care Spending Account at the close of the calendar year will be forfeited. Funds left in my Health Care
Spending Account may be forfeited, per plan rules. See plan documents for more details.
I certify that only eligible medical, dental, vision and/or dependent care IRS qualified expenses will be requested for reimbursement
for myself and/or my IRS eligible dependents incurred during my period of coverage.
Claims I pay with the card, or request for reimbursement, have not been reimbursed and I will not seek reimbursement from any
other plan covering health or dependent care benefits.
My employer and ConnectYourCare, the contract administrator, will not incur any liability resulting from either my participation in any
Spending Account or my failure to sign or accurately complete this Enrollment Form.
I have read and agree to the terms of participation and any applicable certifications in this form and the plan documents. Any previous
election and agreement under the Plan relating to the same Benefits, including any prior Election Form/Salary Reduction Agreement, is
hereby revoked.
Account Holder Signature:
Date:
® 2020 ConnectYourCare
Form_StateofOhio_Enrollment_10.15.2020
Flexible Spending Account
Department of
Enrollment Form
Administrative Services
Use this form to enroll in your Flexible Spending Accounts. Forms must be completed by October 30, 2020. Please complete
all entries on this form. Then print, sign, date this form, and submit the completed form to:
Postal:
Fax: 866-872-7047
ConnectYourCare
Want an easier way to enroll? Enroll online at
P.O. Box 622337
www.connectyourcare.com/stateofohio and skip the paper form!
Orlando, FL 32862-2337
STEP 1: Personal Information
First Name:
Last Name:
Plan Effective
Employee ID:
__ __ /__ __ /__ __ __ __
Date:
Permanent
City:
State:
Zip Code:
Address:
Date of Birth:
Email Address:
__ __ /__ __ /__ __ __ __
(Month/Day/Year)
Marital Status:
Enrollment
o Single o Married o Divorced
o New enrollment
o Re-enrollment
Status:
o Widowed
STEP 2: Health Care Spending Account Elections
(Select Limited Purpose Heath Care Spending Account, which is
limited to dental and vision expenses, if you are enrolled or plan to enroll in the HDHP with a Health Savings Account (HSA) plan.)
o Select Health Care Spending Account (HCSA)
o Select Limited Purpose Health Care Spending Account (LPSA)
I. Annual Employee Contribution
(Not to Exceed Contribution Maximums*)
*For 2021, Health Care Spending Account contributions are limited to a minimum of $240 and a maximum of $2,500 each year. The limit is per person; a
married couple may each contribute up to the specified limit.
STEP 3: Dependent Care Spending Account Elections
o Select Dependent Care Spending Account (DCSA)
I. Annual Employee Contribution
(Not to Exceed Contribution Maximums**)
**Couples who are married and file a joint return, as well as single parents, can contribute a minimum of $240 and up to $5,000 in a Dependent
Care Spending Account. Couples who are married and file separately can put a maximum of $2,500 each into a Dependent Care Spending Account.
STEP 4: Authorization and Certification
I understand that:
I hereby authorize my employer to reduce my gross salary before Medicare, local, state, and federal income taxes are calculated
by the total amount of annual salary deduction indicated above. This election will expire at the end of the calendar year, and I must
make a new election each year.
I am not permitted to change my elections during the calendar year unless the change is due to and in accordance with certain
recognized IRS regulations for change in status events and as allowed in the plan documents.
Funds left in my Dependent Care Spending Account at the close of the calendar year will be forfeited. Funds left in my Health Care
Spending Account may be forfeited, per plan rules. See plan documents for more details.
I certify that only eligible medical, dental, vision and/or dependent care IRS qualified expenses will be requested for reimbursement
for myself and/or my IRS eligible dependents incurred during my period of coverage.
Claims I pay with the card, or request for reimbursement, have not been reimbursed and I will not seek reimbursement from any
other plan covering health or dependent care benefits.
My employer and ConnectYourCare, the contract administrator, will not incur any liability resulting from either my participation in any
Spending Account or my failure to sign or accurately complete this Enrollment Form.
I have read and agree to the terms of participation and any applicable certifications in this form and the plan documents. Any previous
election and agreement under the Plan relating to the same Benefits, including any prior Election Form/Salary Reduction Agreement, is
hereby revoked.
Account Holder Signature:
Date:
® 2020 ConnectYourCare
Form_StateofOhio_Enrollment_10.15.2020