Fcps Form Hr 135 PDF Details

Understanding the intricacies of the FCPS HR 135 form, designed for Flexible Spending Account (FSA) Enrollment or Changes, is essential for employees looking to manage their healthcare and dependent care expenses efficiently. This document serves as a vital tool for new hires, existing employees during open enrollment periods, and those undergoing life-changing events such as marriage, divorce, or the birth of a child. It allows for the pre-tax allocation of funds towards health care and dependent care expenses, adhering to annual contribution limits set by regulations. The form outlines crucial details such as personal information, election choices for the plan year, and contribution amounts per pay period, alongside authorization terms that acknowledge the pre-tax salary reductions and the conditions tied to eligible services and claim submissions. It also specifies the effective dates of coverage depending on the employment or enrollment scenario, including the calculation guide for remaining pay periods for flexible election changes. Notably, it includes provisions related to forfeiture of unused funds, emphasizing the "use it or lose it" nature of FSA accounts as governed by IRS rules. Furthermore, it provides guidance on how to submit the form, the importance of keeping copies for personal records, and avenues for obtaining more information or assistance. Such a comprehensive approach ensures employees are well-informed on how to navigate and maximize their benefits through the FSA program, ultimately enhancing their financial and personal well-being.

QuestionAnswer
Form NameFcps Form Hr 135
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfcps direct deposit form, edu, UConnect, FCPS

Form Preview Example

Flexible Spending Account (FSA) Enrollment/Change Form

1. Your Information

 

Your Name (Last, First, Middle)

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

SSN or Employee ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your Home Address (street and apt. number)

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Phone

 

 

 

 

 

 

Work Phone

 

 

 

 

 

 

 

 

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Reason for submitting form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

– Check the appropriate box below and complete Sections 3 & 4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Employee

 

 

 

Open Enrollment

 

Divorce

 

 

 

Marriage

Birth of Child

 

 

 

 

 

 

 

 

 

 

 

Other (please specify):

Date Occurred:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Indicate Your Election(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am electing to participate for Plan Year: _____________________________ (indicate calendar year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of Pay Periods

 

 

 

 

 

 

Annual Election Amount

 

 

 

 

 

 

Contribution Per Pay Period

 

Remaining in the Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year

 

 

 

Note: For mid-year changes, indicate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(see reverse side)

 

 

 

 

 

 

new annual election amount

 

Health Care

$

 

,

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

X

 

 

 

 

 

= $

 

 

,

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spending

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Election

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cannot exceed $2,500 per year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent

$

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

X

 

 

 

 

 

=$

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Day Care)

Note: dependents must be under 13, unless disabled

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spending

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and incapable of self support.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cannot exceed $5,000 per household

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Election

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Authorization

I elect to participate in the FCPS Flexible Spending Account plan and agree to be bound by the terms and conditions of the plan. I understand the contribution(s) I have elected will be made with pre-tax salary reductions and that such reductions reduce my compensation for Social Security benefit purposes. I understand that this agreement is only for eligible services provided during the plan year and that said services must be provided before submission of claims for reimbursement. I also understand that I am making a binding election for the entire Plan Year unless I have a qualified change of status as defined by IRS regulations. Any salary deductions that have not been used for expenses incurred in the Current plan Year noted above will be forfeited. I have until March 31 following the end of the plan year to submit claims.

Employee Signature: ___________________________________

Date: ___________________________

HR-135 8/13

-CONTINUED ON REVERSE SIDE-

Effective Date of Coverage

•If you are a new employee and want to participate in the FSA program, you must enroll within 30 days of your hire date.

•If you are enrolling mid-year, your participation in the FSA program becomes effective on the first day of the month following the date your form is received by the Office of Benefit Services.

•If you enroll during open enrollment, your participation in the FSA program becomes effective on January 1.

•Your participation in the FSA program ends December 31 of the calendar year in which you enroll, unless you terminate employment mid-year.

•For monthly-paid employees, deductions are taken 10 months of the year (January – June, and September – December). For bi-weekly-paid employees, deductions are taken 9 months of the year (January – June, and October – December). No deductions are taken in July and August and September (bi-weekly).

How to Calculate the Number of Remaining Pay Periods for Your Flex Election

New Hires/Qualifying Event Changes - If your

And You Are Paid Monthly - The

And You Are Paid Bi-Weekly - The

form is received by the Office of Benefit

number of remaining pay periods for the

number of remaining pay periods for the

Services by this date:

Plan Year are:

Plan Year are

 

 

 

December 31

10

20

January 31

9

18

February 28

8

16

March 31

7

14

April 30

6

12

May 31

5

10

June 30

4

7

 

 

 

July 31

4

7

August 31

4

7

September 30

3

7

October 31

2

5

November 30

1

2

Use or Lose Provisions

Both accounts are subject to forfeiture rules as defined by the Internal Revenue Service. If you do not use the money in your health care account or dependent care account within the plan year (January 1–December 31), you will lose that money. Expenses must be incurred during the period in which you are enrolled. You have until March 31 to submit claims for the past calendar year. If you terminate employment during the month of June, claims must be incurred by August 31st to be eligible for reimbursement. If you terminate at other times of the year, claims must be incurred by the end of the month in which you terminate employment.

Where to Get More Information

More information about Flexible Spending Account Program can be found at www.fcps.edu, search Flexible Spending Accounts.

How to Submit Your Form

Scan and e-mail form to:

HRBenefitsEnrollment@fcps.edu

Or fax to:

Benefits Processing at 571-423-5000

Or mail completed form to:

Department of Human Resources

 

Office of Benefit Services, Suite 2700

 

8115 Gatehouse Road

 

Falls Church, VA 22042

If you fax your form, remember to keep a copy for your records as well as a copy of your fax machine’s transmission report as documentation that we received the form by the deadline. Forms that are received after applicable deadlines cannot be accepted. You are encouraged to log onto UConnect three business days after successfully sending your completed paperwork to the Office of Benefits Services to verify your request was processed.

Questions? Contact the HR Client Service Center at 571-423-3000 or 1-800-831-4331 or email your questions to hrquestions@fcps.edu

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