Free 50673.PDF - Indiana

APPLICATION TO PARTICIPATE
RETIREE FLEXIBLE SPENDING PROGRAM State Form 50673 (R / 1-02)

Open Enrollment / Confirmation to Participate: Please complete and return this form to the State Personnel Department to confirm your participation in the Retiree Flexible Spending Program (RFSP). This form confirms your initial option selection(s) and/or allows you to make any changes. If this form is not returned, your initial choice will be applied. You must inform the State Personnel Department in writing of any address changes. _________________________________________________
Print Name (Last, First, Middle Initial)

__________________________
Social Security Number

________________________________________________________________________________
Print Address: Street, Apt. #, City, State, Zip Code Area code / Phone number

I understand that I must meet the criteria established for eligible retiree: · Have at least ten (10) years of creditable service with state agencies; · Have accrued but unused and uncompensated vacation, sick, or personal leave as of my retirement date. "Retire" means terminate state employment at a time when you are entitled to begin receiving pension benefits from a public pension plan as a consequence of your state service. Please refer to the current handbook on retirement benefits published by the Public Employees' Retirement Fund or the Teachers' Retirement Fund. I choose to participate in the following option(s). Place check mark beside option(s).
1. _____ 2. _____ 3. _____ 4. _____

Early retiree medical insurance premiums Dependent care assistance account. Medical reimbursement account. Cash.

Amount designated $__________ Amount designated $ __________ Amount designated $ __________ Amount designated $ __________

(Must meet Early Retiree Insurance Program requirements and complete required application.)

(This option does not make reimbursement for paid insurance premiums.)

Corrections or adjustments to the estimated amount of leave available at the time of retirement may be necessary and will be reported to your agency. If it is determined you do not qualify to participate in the program, your agency will be notified. · · · I understand that up to the $5,000 maximum will be directed to the RFSP in January of the plan year succeeding my date of retirement. I understand that these funds are subject to normal tax deductions prior to being disbursed. I understand that my election under this program is irrevocable. I understand that the amount determined as a benefit under this program and allocated to a flexible spending account on my behalf is available for one calendar year only.

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· · · · · · ·

I understand that any money not expended for the designated purpose within the plan year is forfeited. I understand that the provisions of this section, 31 IAC 4-8-1, are subject to any restrictions imposed by the Internal Revenue Service. In the event of my death before retirement, my designated beneficiary or my estate will be paid the amount that would have been disbursed on my behalf as an eligible retiree in the Retiree Flexible Spending Program. In the event of my death after retirement but before January 1 of the plan year, my surviving dependent may make the election from the available options. In the event of my death, or the death of my spouse, during the plan year, the survivor may make a new election from the available options. In the event neither my spouse nor I survive the plan year, any surviving dependents may make a new election and submit claims for qualified expenditures incurred during the plan year. A copy of the Death Certificate must be attached in the event of death.

______________________________________
Retiree or Designated Beneficiary Signature

__________________________
Date

If signed by Designated Beneficiary, please give Retiree's date of death and attach a copy of the death certificate: _______________________.

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