Our County
I Want To...
- Apply For/Renew
- Find
- Pay For
- Report
- Subscribe To
- Volunteer
Residents
Business
DEPARTMENTS A-Z

Jobs
Document Search
FAQs

Locations
Jobs
Document Search
FAQs

A | A | A

Our County
I Want To...
- Apply For/Renew
- Find
- Pay For
- Report
- Subscribe To
- Volunteer
Residents
Business
DEPARTMENTS A-Z

About St. Louis County

Board of Commissioners

Social Media

Other Boards & Committees

Apply For/Renew
Find

Pay For
Report

Subscribe To

Volunteer

Assistance and Support
Courts/Law
Elections/Voting

Environmental Topics
Health/Medical
Human Interest & Recreation

Natural Disasters
Permits, Licenses and Records
Property/Home

Public Safety
Roads/Transit

Cannabis Information
Do Business With Us

Economic Development
Permits, Licenses and Records

Property Development
Purchasing & Procurement

Recycling & Waste

Administration
Assessor
Attorney
Auditor
Board of Commissioners
The Depot

Economic & Community Development
Environmental Services
Extension Office
Human Resources
Information Technology
Land & Minerals

Law Library
Planning & Zoning
Property Management
Public Health & Human Services
Public Records

Public Works
Purchasing
Safety & Risk Management
Sheriff
Veterans Service

Questions about the Tax Forfeiture Class-Action Settlement? Visit MNTaxForfeitureSettlement.com or call 1-833-709-0093

2019 Flexible Spending Enrollment Form

Home / DEPARTMENTS A-Z / Human Resources / Benefits / Flexible Spending / 2019 Flexible Spending Enrollment Form

Saint Louis County

Flex Election Form

Plan Year: 2019

Instructions: To enroll in your employer's flex plan, please complete all required fields and hit Submit.
Social Security # (with dashes):
^\d{3}-\d{2}-\d{4}$
Employee #:
First Name
Last Name

Address

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

Phone
Area CodePhone Number
Other Phone
Area CodePhone Number
Email Address
Your own personal home or work email address is mandatory if you are ordering or renewing a flex debit card. Otherwise, you can provide any email address of your choosing. It will then only be used to email a confirmation of your enrollment.

EMPLOYEE STATUS
Please select one or more of the following options.

Changes

New Hire

Change in Marital Status (marriage, divorce, legal separation, death)

Change in Number of Dependents (birth, adoption, death)

Change in Employment Status (for you, your spouse, or dependents)

Change in Cost or Coverage (for you, your spouse, or dependents)

Other (subject to administrator approval)

Hire date:
Month - Day - Year
Please describe your change in circumstance:
Date circumstances changed:
Month - Day - Year

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.
Account Elections
Please enter the amount(s) per pay period for the account(s) you want to see the annual amount(s).
Health Care Reimbursement Account - HCRA
Will you or your spouse have Health Savings Account contributions in 2019?

Yes No
Number of Pay Periods - HCRA
Annual Amount - HCRA
$2,700 max
Dependent Care Reimbursement Account - DCRA
Number of Pay Periods - DCRA
Annual Amount - DCRA
$5,000 max
Adoption Reimbursement Account - ARA
Number of Pay Periods - ARA
Annual Amount - ARA
$13,840 max

Debit Card Application (optional):
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.

Debit Card Options

Renew my existing, unexpired flex debit card(s) ($18 for the first set of two, $5 for each additional set)

I do not have a flex debit card and would like one issued to me ($18 for a set of two)

I would like a second set (2) of flex debit cards (additional $5)

I would like a third set (2) of debit cards issued (additional $5)

No debit card needed

Employee Signature
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
Employee Signature:

By checking this box, I declare that I have completed and reviewed all the necessary information provided above.
Current Date: Sunday, December 15, 2024
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.
Captcha

Resources

Jobs
Locations and Directions
Reports, Forms and Publications
News and Updates
Boards and Committees

Policies

American with Disabilities Act (ADA) compliance
Website Accessibility
Website Privacy Policy and Disclaimer
Social Media Policy
Limited English Proficiency (LEP)
Emergency Conditions Policy for employees
Snow Removal Policy
Complete Policy Manual of the St. Louis County Board
Transportation Sales Tax

Contact Us

St. Louis County Offices

Duluth	(218) 726-2000
Ely	(218) 365-2399
Hibbing	(218) 312-8100
Virginia	(218) 749-7100
Toll Free	(800) 450-9777

Employee Access

2019 Flexible Spending Enrollment Form

Saint Louis County

EMPLOYEE STATUS

Account Elections

Debit Card Application (optional):

Resources

Policies

Contact Us

St. Louis County Offices