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.
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.