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2021 Flexible Spending Enrollment Form

Home / DEPARTMENTS A-Z / Human Resources / Benefits / Flexible Spending / 2021 Flexible Spending Enrollment Form

Saint Louis County

Flex Election Form

Plan Year: 2021

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}$

I am currently enrolled in the following flexible spending accounts (FSA) for 2021:

Dependent Care (DCAP) Account (Enter your current annual election amount on future screen)

Health (HCRA) Account (Enter your current annual election amount on future screen)

Adoption (ARA) Account (Enter your current annual election amount on future screen)

All of the above (exit this form, you are in the wrong place)

None

I don't know (exit this form and call 218.726.2393 to find out)

I want to enroll in the following FSA accounts for 2021:

Dependent Care (DCAP) Account

Health (HCRA) Account

Adoption (ARA) Account

None (exit this form, you are in the wrong place)

I want change my flex amounts (do this in the flex amendment form, use this form to begin a flex account)

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.

Your Status, Select All that Apply

New Hire
Special Enrollment under CAA law
Hire date:
Month - Day - Year

Account Elections
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. .
Will you or your spouse have Health Savings Account contributions in 2021?

Yes No
NOTE: If you and your family members only health coverage is with St. Louis County/ARC you can safely answer no. If you are unsure call 218-725-5056 to inquire. If you answer yes, you will be limited to dental and vision reimbursements for all or part of the year.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Health-Care-Reimbursement-Account (HCRA) Annual Amount
Max is $2750 per calendar year, enter $0 to waive it
Deduct my annual election amount evenly over:

26 pay periods (entire calendar year)
Remaining pay periods left in the calendar year
Others
Note: This flex account type is also known as a Health FSA or Health Flexible Spending Account. You can reimburse eligible medical expenses incurred by your or your family members.
Dependent Care Reimbursement Account (DCRA) Annual Amount
Max is $5,000 per tax return, enter $0 to waive
Deduct my annual election amount evenly over:

26 pay periods (entire calendar year)
Remaining pay periods left in the calendar year
Others
Note: This flex account type is also called a DCAP or dependent care assistance program. The only eligible expense in this account type is daycare.
Adoption Reimbursement Account (ARA) Annual Amount
Max is $14,400 in 2021, enter $0 to waive
Deduct my annual election amount evenly over:

26 pay periods (entire calendar year)
Remaining pay periods left in the calendar year
Others

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

I do not have a flex debit card please issue me 2 cards ($18)

My flex debit card is expired/expiring prior to 3/15/22, please issue me new 2 new cards ($18)

My flex debit card(s) will not expire before 3/15/22 and I will continue to use them in 2021 ($18)

My flex debit card(s) will not expire before 3/15/22 but I will not use them in 2021 ($0)

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.
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