Human Resources Department Building E19-215 Massachusetts Institute of Technology 77 Massachusetts Avenue Cambridge, MA 02139-4307 (617) 253-6151 MIT FLEXIBLE SPENDING ACCOUNT ENROLLMENT/CHANGE FORM If you are a new employee, your form must be returned within 31 days of your date of hire, or from the date you received your New Hire Kit, whichever is later. 1 . P E R S O N A L I N F O R M AT I O N Last Name First Name Middle Initial Home Address City State Office Address MIT Extension MIT ID Zip Code Home Telephone Employment Date 2 . F L E X I B L E S P E N D I N G A C C O U N T I N F O R M AT I O N MEDICAL-DENTAL ACCOUNT (Health Care) ENROLLMENT CHANGE DEPENDENT CARE ACCOUNT CANCELLATION ENROLLMENT CHANGE CANCELLATION $ $ Amount to be deducted for the current calendar year* Amount to be deducted for the current calendar year* *Minimum amount is $104.00/year *Minimum amount is 104.00/year Maximum is $,00/year per individual Maximum is $5,000/year per household 3 . A C K N O W L E D G M E N T / S I G N AT U R E I authorize MIT to take out of my pay the pre-tax contributions indicated by my election(s). I understand that by authorizing pre-tax contributions to a Flexible Spending Account, I cannot change my elections under this plan during the calendar year unless I have a change in my personal situation that would, under federal law, permit modification of my elections. I have read the limitations on the back of this form. Employee Signature Date FOR OFFICE USE ONLY NEW HIRE/NEWLY ELIGIBLE Appointment Start Date LIFE EVENT ____________________________ DATE OF EVENT End Date Claim Period Start Date Benefits Administrator Approval Remarks Date GUIDELINES FOR FSA ENROLLMENT/CHANGES In exchange for the tax advantage of before-tax premiums payments, you are prohibited from enrolling in, cancelling or making any changes in the level of your FSA elections outside of open enrollment, unless you have an allowable change in family or employment status. The change in the level of your coverage must be consistent with your change in family or employment status. To make a change in the level of your FSA elections outside of open enrollment, a Flexible Spending Account Enrollment/Change Form must be received in the Benefits Office within 31 days of the event and the change will be effective on the date of the event. The following are examples of changes in family status: The following are examples of changes in employment status: - Marriage/Divorce - Beginning of a domestic partner relationship - End of a domestic partner relationship - Beginning or end of extended sick leave - Beginning or end of extended illness leave - Beginning or end of leave of absence of three months or longer - Beginning or end of sabbatical leave - Adoption or birth of a child - Death of a spouse, domestic partner or dependent - Your dependent marries, reaches the age limit for plan coverage or is no longer a full time student - Your spouse/domestic partner gains or loses employment FSA elections made on this form are effective as of the event date. By electing to participate in a Health Care Flexible Account, a Dependent Care Account, or both, you agree to the following: 1. You can receive reimbursements only for qualified expenses incurred during the plan year and after the effective date of your enrollment, as described in the Flexible Spending Account booklet. 2. Any unused amount remaining in your Health Care and/or Dependent Care Expense Account(s) three months after the plan year will be forfeited. 3. It may be more advantageous for you to use the tax credit available through the Internal Revenue Code when filing your annual income tax return. You should consult a tax professional for assistance with which option provides a more favorable result for you. 4. If you receive reimbursements for services that are not eligible, or if the IRS rules that FSA does not meet the requirements for reducing taxable income, you agree on demand to reimburse the Institute for any liability it may incur for failure to withhold federal and state income tax, up to the amount of additional tax actually owed by you. 5. MIT cannot guarantee the tax treatment of FSA deposits as described in the FSA booklet. 6. You cannot change or revoke this agreement during the plan year unless there is a change in your status as described above. To change or revoke this agreement, a FSA Enrollment Change/Form must be received in the Benefits Office within 31 days of the change in your status, and the change/revocation will be effective as of the date of your status change. 7. MIT is required under the Internal Revenue Code to conduct the Nondiscrimination testing. The plan Administrator may reduce or cancel your salary deduction or otherwise modify this agreement if it is necessary to satisfy provisions of the Internal Revenue Code. 8. If you use the debit card for your Health Care Flexible Spending Account you may be asked to provide substantiation of the expenses to the administrator to satisfy the Internal Revenue Code regulations. Failure to provide the require documentation will result in these charges being re-characterized as ineligible expenses and the reimbursement you previously received will be revised to report it as taxable income.
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