Flexible Spending Account (FSA) Change Form
Employee Information
Employee Name
Employee ID
Department
Email
Phone Number
Type of Change
Enroll
Increase Contribution
Decrease Contribution
Terminate Participation
Effective Date of Change
Select FSA Plan(s) and Amount
Medical Expense FSA
Annual Election Amount
Per Pay Period Amount
Dependent Care FSA
Annual Election Amount
Per Pay Period Amount
Reason for Change
Marriage
Divorce
Birth/Adoption
Change in Dependent Status
Other
If Other, please specify:
Additional Comments
Employee Signature
Date