Follow the steps to complete the authorization form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in your personal information in the designated fields. This includes your full name, employer's name, mailing address, plan year, city, state, zip code, Social Security number (SSN), email address, daytime phone number, and date of birth (DOB). Ensure all information is accurate to prevent processing delays.
3. Select how often you are paid by checking the appropriate box (weekly, bi-weekly, monthly, semi-monthly, or other). If applicable, indicate whether you are a municipal employee or a school employee by marking the corresponding boxes.
4. Proceed to specify your contributions towards the Flexible Spending Accounts (FSA). For the FSA Dependent/Day Care Account, indicate the amount you elect to contribute for the plan year (maximum of $5,000). For the FSA Health Care Account, specify your contribution amount (up to $3,050 or the employer's plan maximum if it is lower). Remember not to include insurance premiums.
5. If applicable, indicate any FSA administrative fees for the plan year.
6. Provide your direct deposit information if not already on file. Authorize Cafeteria Plan Advisors, Inc. to deposit claim reimbursements directly into your checking or savings account. Fill in your bank name, check routing number, and account number accurately.
7. Read the certification section carefully. By signing, you authorize the salary reduction agreement and confirm your understanding of the terms and conditions, including fund forfeiture policies and eligibility criteria.
8. Sign and date the form at the designated area to validate your application.
9. Once completed, save your changes, and proceed to download, print, or share the form as necessary. Ensure you submit the form via email to the provided address: info@cpa125.com.

Complete your authorization for pre-tax payroll reduction online today!