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“Take Home Pay” With & Without FSAs
Increase in Take Home Pay
$2,500 Maximum Contribution for
Health Care FSA or Limited Health Care FSA
$5,000 Maximum Contribution for
Dependent Care FSA
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Per IRS Regulat ions: (1 ) Only IRS quali f i ed dependents are
el igib le for benefit s from th ese plans.
(2)Funds cannot rol lover f rom year to year; you must use the
funds or lose them.
Health Care Flexible Spending Arrangement
$
Dependent Care Flexible Spending Arrangement
$
H D
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.
The Benny debit card is
but not always !!
Be prepared to submit copies of receipts and
other documentation upon request.
http://www.mybenny.com/
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Not sure if an expense is eligible? Call (Flexible Benefits
System)
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http://tonova.typepad.com/.a/6a00d8341c556453ef01156e801ae3970c-500wihttp://tonova.typepad.com/.a/6a00d8341c556453ef01156e801ae3970c-500wi
-
The Benny debit card is
but not always !!
Be prepared to submit copies of receipts and
other documentation upon request.
-
H Print all information
Keep a copy of the reimbursement form and all receipts
Make copies of this form to use for future claims
New Address
All documentation must be legible, i temized and include all the
items listed below
$
$
$
$
$
$
$
All information must be completed in order to process your
Reimbursement. $
Signature
(required): Date:
IMPORTANT—All reimbursement forms must be completely filled out
with dates of service, type of
service and amounts you are claiming. They must be signed, dated
and include the last 4-digits of your
Social Security Number. If the form is not complete, it will be
returned to you for completion.
Reimbursement paperwork must be sent to the address/fax noted
below and will be reimbursed on the
next processing cycle.
-
Print all information
Keep a copy of the reimbursement form and all receipts
Make copies of this form to use for future claims
New Address
(must appear on the receipt)
$
$
$
$
$
All information must be completed in order to process your
Reimbursement. $
Signature
(required): Date:
IMPORTANT—All reimbursement forms must be completely filled out
with dates of service, type of service
and amounts you are claiming. They must be signed, dated and
include the last 4-digits of your Social Security
Number. If the form is not complete, it will be returned to you
for completion. Reimbursement paperwork
must be sent to the address/fax noted below and will be
reimbursed on the next processing cycle.
D
