SECTION D: FSA & Begins: / / Ends: / / Is first plan year a short plan year? Yes No If yes, beginning: / / Plan Options Healthcare Flexible Spending Account (HCFSA) Yes No Is an HSA Compatible FSA offered? Yes No Dependent Care Flexible Spending Account (DCFSA) Yes No HCFSA Maximum election amount: *$2,600 Other: (cannot exceed IRS Maximum of $2,600) (*If short plan year, max benefit of $2,600 must be prorated by month) Employer contribution applies? Yes, amount: $ No DCFSA Maximum election amount: *$5,000 Other: (cannot exceed IRS Maximum of $5,000) *The statutory limit for pretax Dependent Care benefits is $5,000 per calendar year. Employer contribution applies? Yes, amount: $ No 90 Days Other. If other, provide number of days: for active participants
SECTION D: FSA & Begins: / / Ends: / / Is first plan year a short plan year? Yes No If yes, beginning: / / Plan Options Healthcare Flexible Spending Account (HCFSA) Yes No Is an HSA Compatible FSA offered? Yes No Dependent Care Flexible Spending Account (DCFSA) Yes No HCFSA Maximum election amount: *$2,600 Other: (cannot exceed IRS Maximum of $2,600) (*If short plan year, max benefit of $2,600 must be prorated by month) Employer contribution applies? Yes, amount: $ No DCFSA Maximum election amount: *$5,000 Other: (cannot exceed IRS Maximum of $5,000) *The statutory limit for pretax Dependent Care benefits is $5,000 per calendar year. Employer contribution applies? Yes, amount: $ No for active participants 90 Days Other. If other, provide number of days:
Plan-Survey.docx