FSA Enrollment Form - Further

Employee Information

SSN*

Phone*

Name*

First Name

Initial (optional)

Last Name

Address*

Address Line 1

City

State

ZIP Code

Date of Birth*

Dependent Care Flexible Spending Account

Annual Contribution Amount* $

I want to contribute this amount to my Dependent Care Flexible Spending Account during this plan year. I understand that the IRS Maximum is $5000 ($2500 if married by filing separate tax returns). I understand this amount will be deducted from my pay throughout the plan year.

Signature

Email Address Where You Will Sign This Document*

Also Text a Link To My Phone:

After you sign here, you will receive an email or text with a link. When you follow that link, you will complete your selection by APPROVING the document.

Required*

I understand that my form will not be complete until I approve the signature via text or email.

Signature*

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Use your mouse or finger to draw your signature above

Date/Time