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Personal Information: Participant Name: Employer: Mailing Address: Plan Year: City/Town, State: ZIP: SSN: DOB: E-Mail: Daytime Phone: work I work for (check one): Schools City I am paid (check one): Bi-weekly 20 (Para) Bi-weekly 20 (Teacher) Bi-weekly 26 (Admin) Weekly 52 Weekly 42 (Clerks) Weekly 40 (Café/Bus) Flexible Spending Account (FSA) Benefit Selections: CAFETERIA PLAN ADVISORS 120 Longwater Dr., Suite 102 Norwell, MA 02061 Tel.: [PHONE REDACTED] Authorization for Pre-Tax Payroll Reduction Enrollment Deadline is May 30, 2024. * Enroll or Re-enroll by 5/30/2024. Late Enrollments not Accepted. * Direct Deposit Info. Direct deposit is our preferred method of expense reimbursement. Unless your banking info. is already on file with Cafeteria Plan Advisors, please set up direct deposit via your account portal once you receive enrollment confirmation. Certification. I hereby authorize a salary reduction agreement for the amount(s) shown above and understand that: Cafeteria Plan Advisors will hold these funds until eligible expenses are incurred and a claim is submitted. Funds may be forfeited in accordance with Internal Revenue Service (IRS) Publication 969 if eligible expenses are not spent or submitted for reimbursement by plan year deadline or purchased utilizing the provided debit card within the plan year or the date upon which employment ends, whichever comes first. All claims for the Plan Year must be submitted within ninety (90) days of the end of the Plan Year. Your Health Care FSA plan has a Rollover option. Eligible balances roll over to the next plan year when you re-enroll in the Health Care FSA for the new plan year and the rollover occurs after the current plan year’s 90-day runout period ends. This election cannot be revoked or changed during the plan year unless the participant experiences a qualifying event as defined by the IRS. Current participants must enroll each plan year; re-enrollment is not automatic. Health Care FSA cards, if offered through your employer’s plan, will reload at the start of each plan year when you re-enroll; keep until they expire. Additional certification for Dependent Care Plan Participants: I understand that the Dependent Care Reimbursement Plan Guidelines can be found at CPA125.com and I qualify to participate in the FSA Dependent Care plan. I agree to notify the plan administrator in writing within 30 days should I experience a change in need or no longer meet the IRS’s eligibility criteria. Dependents must qualify under regulations set forth in IRC sections 152 and 129. Tax advice: It is suggested you consult with a tax advisor to determine your tax savings and/or limits on tax deductions. Signature: Date: A system-generated e-mail confirmation will be sent once your enrollment is processed. personal City of Salem Health Care FSA Election: for the plan year for employee, legal spouse, and eligible dependents’ qualified medical, dental, vision expenses. Benefit card included. Max. Annual Election: $3,200. Rollover Option: Any unspent Health Care balance—up to $640— will roll over to the next plan year if you re-enroll for that next plan year. (Note: The rollover limit for the 2023-2024 plan year is $610.) Ineligibility Note: You are NOT eligible for this plan if you or your spouse have a Health Savings Account Dependent Care FSA Election: for the plan year for qualified day care expenses for eligible dependents under age 13, elderly dependents, and dependents with special needs requiring day care. Max. Annual Election: $5,000 per family. Claim-based plan; no benefit card. Participants must submit claim(s) each plan year to receive accrued funds. Annual Admin. Fees (paid via payroll deduction): If enrolled in Health Care FSA only, $66; Dependent Care FSA only, $54; Health Care and Dependent Care, $66. IF ENROLLED IN A CITY-SPONSORED HEALTH INSURANCE PLAN, THE HEALTH CARE FSA FEE IS WAIVED. 7/1/2024 to 6/30/2025 (Expenses must be incurred between these dates) See Open Enrollment flyer for more FSA benefit plan info. INSTRUCTIONS: If Already in Plan: Re-enrollment is NOT automatic! To enroll for the new plan year via your online account portal, go to cpaemployee.lh1ondemand.com—not the app. Log-in on the left side of the sign-in screen. Once on your account homepage, click the blue ENROLL/RE-ENROLL button and follow the steps to enroll; click Submit at the end. (We recommend printing or saving your enrollment confirmation.) New Enrollees: Complete & return this form as noted: SCHOOL Employees Send form to SCHOOL BENEFITS OFFICE CITY Employees Send form to CITY BENEFITS OFFICE