FSA Forms

ITU is pleased to provide the following FSA coverage to all of our benefit eligible employees: Before each calendar year you will be given an opportunity to enroll in a flexible spending account which enables employees to use pre-tax earnings to pay for out-of-pocket medical expenses, such as deductibles and coinsurance, (but not payroll contributions for premiums, as they are already deducted pre-tax). These accounts also allow you to use pre-tax earnings to pay for daycare providers for eligible dependent children and disabled adults (i.e., spouse and parent) who require care when the employee works. Details about acceptable expenses are available in IRS Publication 502 (www.irs.qov).

You must plan carefully when determining your contribution to this account. Any funds that remain unused at the end of the year will be forfeited. You are only eligible to change your contribution amount if you have a family status change. The calendar year plan allows for the following maximum contributions:

You have a grace period to submit claims for expenses incurred between December 1st through November 30th of the previous year. Also keep in mind that if you terminate your employment during the year, you can only submit claims incurred up to the date of termination (unless you continue coverage through COBRA). Any unused funds remaining in your account will not be refunded to you.