FSA Enrollment Form - Human Resources at MIT

Human Resources Department
Building E19-215
Massachusetts Institute of Technology
77 Massachusetts Avenue
Cambridge, MA 02139-4307
(617) 253-6151
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
Office Address
MIT Extension
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
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
Appointment Start Date
____________________________ DATE OF EVENT
End Date
Claim Period Start Date
Benefits Administrator Approval
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
The following are examples of changes in family
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
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