PDF
Word
This version of the form is not currently in use and is provided for reference only. Download this version of
the document
for the current year.
Flexible Spending Account (FSA) Enrollment / Change Form - New Hampshire
Flexible Spending Account (FSA) Enrollment/Change Form is a legal document that was released by the New Hampshire Department of Administrative Services - a government authority operating within New Hampshire.
FAQ
Q: What is a Flexible Spending Account (FSA)?
A: A Flexible Spending Account (FSA) is a benefit offered by some employers that allows you to set aside a portion of your pre-tax salary to pay for eligible medical expenses.
Q: Can I enroll in a Flexible Spending Account (FSA) at any time?
A: No, you can only enroll in a Flexible Spending Account (FSA) during your employer's open enrollment period or within 30 days of a qualifying life event.
Q: What types of expenses are eligible for reimbursement from a Flexible Spending Account (FSA)?
A: Eligible expenses for reimbursement from a Flexible Spending Account (FSA) include medical and dental expenses, prescription medications, and certain over-the-counter items.
Q: Is the money in a Flexible Spending Account (FSA) use-it-or-lose-it?
A: Not necessarily. Employers can offer a grace period or a rollover option, allowing you to use the funds in your Flexible Spending Account (FSA) beyond the end of the plan year.
Q: How much money can I contribute to a Flexible Spending Account (FSA)?
A: The maximum annual contribution limit for a Flexible Spending Account (FSA) is determined by your employer. For 2021, the maximum limit is $2,750.
Q: Can I use my Flexible Spending Account (FSA) funds for my dependents' expenses?
A: Yes, you can use your Flexible Spending Account (FSA) funds to pay for eligible medical expenses for your dependents, such as your spouse and children.
Q: Can I use my Flexible Spending Account (FSA) for cosmetic procedures?
A: In most cases, cosmetic procedures are not eligible for reimbursement from a Flexible Spending Account (FSA), unless they are deemed medically necessary.
Q: What happens to my Flexible Spending Account (FSA) if I change jobs?
A: If you change jobs, you may lose the funds in your Flexible Spending Account (FSA). However, some employers offer a grace period or a rollover option, allowing you to use the funds.
Q: Can I change my Flexible Spending Account (FSA) contribution amount mid-year?
A: In general, you can only change your Flexible Spending Account (FSA) contribution amount during your employer's open enrollment period or within 30 days of a qualifying life event.
Q: What documentation do I need to submit for reimbursement from my Flexible Spending Account (FSA)?
A: You will typically need to submit receipts or other documentation that shows proof of the eligible expenses you are seeking reimbursement for from your Flexible Spending Account (FSA).
Form Details:
- Released on October 21, 2022;
- The latest edition currently provided by the New Hampshire Department of Administrative Services;
- Ready to use and print;
- Easy to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Administrative Services.
