Election form for Health Care FSA and/or Dependent Care FSA contributions, IRS annual limits, use-it-or-lose-it acknowledgment, and payroll deduction authorization.
The Flexible Spending Account (FSA) Election is a ready-to-use employment & hr template you can send for signature in minutes. It is written for 1 signer (employee) and, by default, expires 30 days after it is sent if left unsigned. It covers fsa, flexible spending account, benefits, healthcare, dependent care, irs. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Flexible Spending Account (FSA) Election --- ## Employee Information **Employee Name:** ___________ **Employee ID:** ___________ **Department:** ___________ **Plan Year Effective Date:** ___________ --- ## Section 1 — Health Care FSA Election A Health Care FSA lets you set aside pre-tax dollars to pay for eligible out-of-pocket medical, dental, and vision expenses incurred by you, your spouse, and your dependents during the plan year. **Do you wish to elect a Health Care FSA?** ___________ **Health Care FSA Annual Election Amount:** ___________ The IRS annual contribution limit for Health Care FSAs is **$3,300** for the 2025 plan year. Your annual election may not exceed this limit. Your employer may impose a lower maximum; refer to your Summary Plan Description (SPD) for the plan-specific maximum. **Estimated per-paycheck deduction:** Your elected annual amount will be divided equally across all remaining pay periods in the plan year. For example, a $2,400 annual election divided over 24 semi-monthly pay periods equals $100.00 per paycheck. Your payroll department will confirm the per-period amount on your pay statement. ### Eligible Health Care Expenses (partial list) Eligible expenses include but are not limited to: deductibles and copayments, prescription medications, dental treatment, orthodontia (subject to plan rules), vision care including eyeglasses and contact lenses, mental health services, chiropractic care, and certain over-the-counter items as permitted under IRS Notice 2021-15 and the CARES Act. A full list of eligible expenses is available from your Benefits Administrator or at IRS Publication 502. --- ## Section 2 — Dependent Care FSA Election A Dependent Care FSA (also called a Dependent Care Assistance Plan, or DCAP) lets you set aside pre-tax dollars to pay for eligible dependent care expenses that allow you (and your spouse, if married) to work, look for work, or attend school full-time.