Employee benefits division




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CS-1784

Rev 10/2010



State of Michigan

Civil Service Commission



EMPLOYEE BENEFITS DIVISION

Flexible Spending Accounts

Capitol Commons Center, 4th Floor

400 South Pine Street, P.O. Box 30002

Lansing, Michigan 48909

(517) 373-7977 or (800) 505-5011

TDD (517) 241-8046



 Health Care

 Dependent Care




FLEXIBLE SPENDING ACCOUNTS




LIFE EVENT/ELECTION CHANGE FORM

Instructions: Complete this form to report a change in status in either the Health Care or Dependent Care Flexible Spending Account for the current calendar year. Documentation must be provided within 31 days of the qualifying life event in order for the change to be processed. Sign and date the form, attach supporting documentation, retain a copy of the form and the supporting documentation for your records, and mail to the address above or fax to (517) 373-3174. A portion of this information is protected by federal privacy laws and/or state confidentiality requirements. Do not use this form for enrollment.

PLEASE PRINT OR TYPE

Name


     

Daytime Phone


(     )     -      Ext.      

Home Address


     

Employee ID Number


     

City


     

State


  

Zip Code


     

State E-mail Address


     

Current Biweekly Deduction


$      

New Biweekly Deduction


$      

Number of Pay Periods For Deduction


(1 to 26)

     

Life Event (Check one below):

Date of Event


     

Documentation Needed:


(Please send copies)

 1. Birth or Adoption of Child

Birth Certificate/ Legal Documentation

 2. Death of Dependent or Spouse

Death Certificate

 3. Gain or Lose Custody of Dependent

Legal Documentation

 4. Addition of Incapacitated Adult or Child to Household

Documentation to Certify Incapacitation

 5. Legal Separation

Legal Documentation

 6. Divorce

Divorce Decree

 7. Marriage

Marriage License

 8. Significant Change in Dependent Care

Detailed Explanation

 9. Change in Employment Status

Documentation from Employer

 10. Other, Specify:      

Specified by Employee Benefits Division

I authorize the State of Michigan to reduce my gross biweekly salary in the amount specified above in the New Biweekly Deduction box.

I understand that according to Federal Regulation, any money remaining in my account at the end of the year and its corresponding grace period must be forfeited.

I certify that the information provided on this form is true and complete. I understand that any misstatement or falsification of material facts will result in my removal from the Spending Account, and may cause an IRS and/or state audit with possible additional tax, interest, and penalties due.

Employee’s Signature

Date



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