Flexible Spending Account (FSA) / Transportation Reimbursement Account (TRA) Enrollment Form & Compensation Reduction AgreementFlexible Spending Account (Fsa) / Transportation Reimbursement Account (Tra) Enrollment Form & Compensation Reduction Agreement • December 6th, 2019
Name: (Last, First, Middle Initial): Employee #: Home Phone: Work Phone: SSN or FSA Member ID (Required): Mailing Address (Street or PO Box): City: State: Zip Code: Enrollment Information Reason Open Enrollment New Hire Enrollment - Date of Hire : Mid-year Enrollment, Election Change or Cancellation - Date of Qualifying Event: Election ActionFSA Health Care FSA Dependent Care TRA ParkingTRA Mass Transit/Van Pool Enroll/Re-Enroll Enroll/Re-Enroll Enroll/Re-Enroll Enroll/Re-Enroll Mid-Year Election Change Mid-Year Election Change Mid-Year Election Change Mid-Year Election Change Cancel Cancel Cancel Cancel Type of Qualifying Event - if mid-year Health Care or Dependent Care enrollment, election change or cancellation (marriage, divorce, new baby, etc.): Comments: Election Amount Total Election Amount per Calendar Year*FSA Health Care Account - $2500/yr max $ (per calendar year) FSA Dependent Care Account - $5000/yr max $ (per calendar year) TRA Parking
