Get (hcra/dcra) Enrollment Form - Csupomona

Completing the (HCRA/DCRA) Enrollment Form – Csupomona is an essential step for individuals seeking to enroll in dependent care and health care reimbursement accounts. This guide offers clear, step-by-step instructions to help you navigate the form online with ease.

Follow the steps to successfully complete the enrollment form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, select the type of enrollment by checking the appropriate box: 'Open Enrollment', 'New Enrollment', 'Change Due to Permitting Event', or 'Cancellation'.
3. Next, provide your Social Security number in the designated field.
4. Fill in your name in the 'Name' section, ensuring you include both first and last names clearly.
5. Indicate your marital status by selecting either 'Married' or 'Single'.
6. For reimbursement plan elections, specify the monthly deduction amounts for both the Dependent Care Reimbursement Account (DCRA) and the Health Care Reimbursement Account (HCRA). Make sure the amounts fall within the specified limits.
7. Sign and date the coverage statement to acknowledge your understanding of the enrollment terms. Ensure you include your initials in the relevant sections.
8. Complete any additional sections, like the 'Effective Date of Action' and 'Permitting Event Date', providing the necessary details.
9. Conclude the process by reviewing all entries for accuracy. Once verified, save your changes, and choose to download, print, or share the completed form as required.

Take the next step toward your health and dependent care needs by completing your enrollment form online today.