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HomeMy WebLinkAbout2025 FSAP.O. Box 71107 Oakland, CA 94612 1.800.617.4729 1.888.410.7361 ***.sterlingadministration.com 1© 2014 Sterling Administration | rev 10.14 HEALTHCARE FSA ENROLLMENT FORM EMPLOYEE INFORMATION (PLEASE PRINT CLEARLY) City:State:Zip: Date of Birth: Email:Employer Name: Male Female EMPLOYEE INFORMATION (EMPLOYER TO COMPLETE THIS SECTION) Plan Effective Date: Month Date Year First Pay Period Date Effective FIRST NAME SSN #BIRTH DATE GENDER (M or F)LAST NAME DEPENDENT INFORMATION STUDENT (Y or N) I acknowledge and agree to these IRS required conditions for reimbursement. The IRS regulation states four conditions. 1) Any expenses you incur must be within the plan year; 2) Expenses you incur may not be reimbursed by any other source, such as insurance; 3) You must provide proper documentation to receive payment; 4) You cannot change or revoke your election during the plan year unless there is a specific change of status and your employer allows such changes. Signature:Date: RELATIONSHIP (SPOUSE or DEPENDENT) M.I.Last Name: Annual Election (max. annual election: $3,200) Annual Election (max. annual election: $5,000) Employee’s First Name: Social Security #: Employee’s Home Address: Employee’s Home Phone: Flexible Spending Dependent Care Per Pay Period Contribution (your election divided by 24) Period Contribution Per Pay (your election divided by 24) Payroll Schedule Payroll Schedule Please check this box if you also have a health savings account (HSA)