Get Flexible Benefit Plan - Modification Form

Filling out the Flexible Benefit Plan - Modification Form online is a straightforward process. This guide will provide you with step-by-step instructions to ensure that all sections are completed accurately and effectively.

Follow the steps to complete your modification form online.

1. Click ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by providing your personal information. Fill in your name, Social Security number, and select the box if you have a new address. Include your home address, city, state, zip code, daytime phone number, and email address.
3. Review the status changes for modifying your Flex-Plan reimbursement accounts. Indicate if your modification is due to any changes in family status such as marriage, divorce, or changes in employment.
4. In the section for Health Care Reimbursement Account, enter the original annual amount and pay period deduction. Then, update the new annual amount and new pay period deduction as necessary.
5. Next, move to the Dependent Care Reimbursement Account. Similar to the health care section, input the original amounts and make any necessary modifications for the new annual amount and pay period deduction.
6. After completing the sections, provide a brief explanation in the designated area to clarify your reasons for the modification.
7. Ensure you have signed and dated the form. Your employer will also need to complete the payroll effective date and approval signature.
8. Finally, save your changes. You can then download, print, or share the completed form as required.

Start completing your Flexible Benefit Plan - Modification Form online today!