Flexible Spending Account Change Form – Human Resources

Employer *

Employer ID *

Employee ID Number *

This can be found on your K ID card. It should have leading zeros in front of it to make it a 7-digit number. Example: 0123456

Change Effective Date *

This is normally your event change date.

Change Reason *

Employee Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone *

Email *

Enter Email Confirm Email

Date of Birth *

Payroll Frequency *

BiWeekly
Monthly

Original Health Care Flexible Spending Account Contribution Per Pay Period

The maximum total contribution for 2021 is $2750.00. Please multiply your contribution by the number of biweekly or monthly payrolls remaining for the calendar year to make sure you are with in the IRS limits for 2021.

New Health Care Flexible Spending Account Contribution Per Pay Period

The maximum total contribution for 2021 is $2750.00. Please multiply your contribution by the number of biweekly or monthly payrolls remaining for the calendar year to make sure you are with in the IRS limits for 2021.

Original Dependent Care Flexible Spending Account Contribution Per Pay Period

The maximum total contribution for 2021 is $5,000.00. Please multiply your contribution by the number of biweekly or monthly payrolls remaining for the calendar year to make sure you are with in the IRS limits for 2021.

New Dependent Care Flexible Spending Account Contribution Per Pay Period

The maximum total contribution for 2021 is $5,000.00. Please multiply your contribution by the number of biweekly or monthly payrolls remaining for the calendar year to make sure you are with in the IRS limits for 2021.

Spouse/Partner's Name

First Last

Spouse/Partner's Date of Birth

Dependent #1 Name

First Last

Dependent #1 Date of Birth

Dependent #2 Name

First Last

Dependent #2 Date of Birth

Dependent #3 Name

First Last

Dependent #3 Date of Birth

Do you have more than three(3) dependent children?

Yes
No
N/A

Please click here if you have more than 3 dependent children so a member of Human Resources may reach out to you for further enrollment information.

Payroll Deduction Authorization *

I understand that the change in my benefit election must be necessitated by and consistent with the change in status and that the change must be acceptable under the Regulations issued by the Department of Treasury.

Signature *

Date *

BFG FSA Change Form