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GOVERNMENTEmploymentBenefitsFlexible Spending Benefits2018 Flex Spending Form   

Saint Louis County

Flex Election Form

Plan Year: 2018
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Instructions: To enroll in your employer's flex plan, please complete all required fields and hit Submit.
 

 
 
 
 
 

Any email address provided here will be shared with the flex administrator and may be linked to your myflexonline account and may receive personal health information.  An email address is mandatory if you are ordering or renewing a flex debit card.

 
 
 

Please select your accounts and specify the new per pay period and annual total amounts you would like to elect.  Annual total is based on the number of pay periods entered.   The St. Louis County Payroll Calendar may be helpful in determining how many pay periods remain in the calendar year.  If you have questions regarding coverage please contact Beth Menor at 218-725-5056.  All other enrollment questions can be directed to the payroll department at 218-726-2393.

 

Please check at least one of the boxes below.
 

($2,650 max)

($5,000 max)

($13,840 max)

 
 
 
 
 
If you wish to receive reimbursement via the flex debit card please select one or more of the following options.  The associated fees will be deducted from your flex account upon the first deposit of the year.  All debit cards will come in the employee's name, but can be used by any eligible dependent.
 
 
 
 
 
 
 
 
 
I, the undersigned, hereby revoke any and all previous account elections under the Plan and authorize my employer to reduce my cash compensation by deducting, on a pre-tax basis, the amounts elected above. I understand and agree that:

1) the deductions will continue through the end of the applicable Plan Year or the termination of my employment and cannot be changed unless I incur a qualifying change in status event. The amounts I have elected will be available to me for the reimbursement of qualifying expenses according to, and for the period specified in, my employer's Plan Document.

2) I have read and agree to comply with the Internal Revenue Code Regulations and other Plan rules and provisions at the link below. I understand that my employer's Plan Document contains the controlling terms and provisions by which the operations of the Plan are governed.

3) in the event that any reimbursement I may claim and receive under the Plan is later deemed unsubstantiated by the IRS, I hereby acknowledge and accept responsibility, and hold my employer and SuperiorUSA harmless, for any adverse tax consequences that may result. Furthermore, I will notify my employer if I have reason to believe that any reimbursement I receive was for a non-qualified expense.
 
 
Please click the link below for additional information regarding your Flex Elections.

General Provisions.pdf

 
 
 
 
 
Once you have reviewed the information and checked the box above, please press the "Submit" button below to submit your form.  The form will be electronically transmitted to the Payroll Division - Auditor's Office, Duluth Courthouse, Room 201 for approval and submission to SuperiorUSA.  SuperiorUSA will not accept Flex Election Forms directly from employees.  
 
 
 

You will receive immediate confirmation upon submitting this form.  If you are not taken to a confirmation page your form has not been submitted.  Please scroll up and check for errors.  Once you have fixed the errors hit submit again.

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