RCUH Policies and Procedures
of the University of Hawai‘i
Human Resources Department
RCUH Flexible Spending Enrollment/Change Form
Employee Name: RCUH Employee ID #:
PRETAX Flexible Spending Plan Election & Compensation Reduction
IMPORTANT: to completing this form, read the Election Information Sheet and RCUH’s Flexible Spending Plan information brochure, OR refer to policy 3.530 RCUH Flexible Spending Plan. Select an option and indicate your election(s) below:
1) Your election change must be submitted to the RCUH HR Department no later than thirty (30) days after a family status change. 2) Supporting documentation must be submitted to make changes to your enrollment.
Medical Expense Reimbursement Account:
(Maximum annual contribution $2550 = $106.25 / pay period)
$ / Pay Period
Dependent Care Expense Account:
(Maximum annual contribution $5000 = $208.33 / pay period)
$ / Pay Period
PRETAX Transportation Benefits
IMPORTANT: to electing, changing, or cancelling this coverage, read RCUH policy 3.530 RCUH Flexible Spending Plan. These elections will remain in effect and continue automatically until the RCUH HR Department is notified of your wish to terminate or alter your transportation program elections. Select an option and indicate your election(s) below:
Parking Expense Reimbursement
☐ Enrollment $ / Month
(Maximum Limit Per Month: $250.00 / month)
☐ Change $ / Month ☐ Cancel: Parking Expense Reimbursement
Transit Expense Reimbursement
☐ Enrollment $ / Month (Maximum Limit Per Month: $130.00 / month)
☐ Change $ / Month ☐ Cancel: Transit Expense Reimbursement
Deduction occurs the month prior to coverage therefore your
election form must be received at least 30 days in advance.
The Effective Date will be dependent upon submission of this form to RCUH Human Resources. RCUH will send a confirmation email with the effective enrollment date.
I acknowledge that I have reviewed and understand the options available to me for my Employer’s Flexible Spending Plan pursuant to the following: (1) RCUH Policy 3.530 Flexible Spending Plan (2) Internal Revenue Service Code 125 for Pre-Tax Flexible Spending Accounts and/or (3) Internal Revenue Service Code 132 for Pre-Tax Transportation Accounts and will comply accordingly.
I understand that my Employer makes no guarantee that any benefits I elect under this Plan will be excludable from my gross income for federal or state income tax purposes. I understand that it is my obligation to determine whether or not each payment made under this Plan is excludable from my gross income for federal and state income or Social Security tax and to notify my Employer if I am aware that any particular payment may not be excludable. I agree that if I receive one or more reimbursements under this Plan that are not excludable from income under the Internal Revenue Code, I will indemnify and reimburse my Employer for any tax that may be due on such reimbursement.
I understand that failure to comply with the above or providing inaccurate information or falsifying the information contained in this form may result in disciplinary action including termination of employment. Legal action may be brought against me and/or my Dependents/Spouse/Domestic Partner/Civil Union Partner for any losses, damages (including, but not limited to reasonable attorneys’ fees and other legal expenses), financial or otherwise, due to false statements provided on this enrollment form or for failure to timely notify RCUH of changed circumstances as required.
Employee Signature: Date:
Submit via email: [email protected] or Fax: 808-956-5022 .
RCUH USE ONLY Authorized By:
Input By / Date
Edit By / Date
RCUH Form B-5F rev 10/27/15, 03/30/16