2025 Flexible Spending Amendment Form

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2025 Flexible Spending Amendment Form

Home / DEPARTMENTS A-Z / Human Resources / Benefits / Flexible Spending / 2025 Flexible Spending Amendment Form

Saint Louis County

Flex Amendment Form

Plan Year: 2025

Instructions: 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 Status, Select All that Apply

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 of Insurance (for you, your spouse, or dependents)

Change in Cost or Need for Daycare

Other (subject to administrator approval)

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

Check all applicable change types

I want to STOP my DAYCARE flex deductions

I want to STOP my MEDICAL flex deductions

I want to INCREASE my DAYCARE flex deductions

I want to INCREASE my MEDICAL flex deductions

I want to DECREASE my DAYCARE flex deductions

I want to DECREASE my MEDICAL flex deductions

I want to ADD DAYCARE flex deductions (exit this form, you need the flex enrollment form)

I want to ADD MEDICAL flex deductions (exit this form, you need the flex enrollment form)

New Per Pay Period MEDICAL Flex Deduction Amount, if applicable
New Per Pay Period DAYCARE Flex Deduction Amount, if applicable
IMPORTANT! Pause briefly after checking a box to see if more fields appear.

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: Saturday, April 4, 2026
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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