Flexible Spending Account Change Form

Please complete the form below to make changes in your Flexible Spending Account. Changes must be made within 30 days of qualifying event date to be eligible for Special Enrollment.

BFG FSA Change Form

  • 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
  • This is normally your event change date.
  • 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.
  • 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.
  • 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.
  • 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.
    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.