Peralta Community College District - Flexible Spending Arrangement Enrollment Form - Plan Year 2023

Sep 19, 2026

Enrollment form for a Peralta Community College District Flexible Spending Arrangement with Plan Year 1/1/2023–12/31/2023 and a grace period through 3/15/2024. Includes employee information, benefit elections for Health Care FSA and Day Care FSA, plus Premium Conversion handling, Navia debit card use, and direct deposit reimbursement options. Provides signature authorization and guidance on qualifying expenses, tax rules, use-it or lose-it, grace period, claim runout, and claim check reissues.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Employee Information

Benefit Election (Section 125)

Debit Card & Direct Deposit

Signature

Additional Information

YGT Peralta Community College District – Flexible Spending Arrangement Enrollment Form Plan Year: 1/1/2023 – 12/31/2023 with Grace Period through 3/15/2024 Last Day to Submit Claims: 3/31/2024 Employee Information – Please write legibly to ensure proper enrollment | Last Name, First Name | | | SSN / Employee ID \# | | | --- | --- | --- | --- | --- | | | | | | | | Home Address (Street, City, State, Zip Code) | | | | | | | | | | | | Date of Birth
(MM/DD/YYYY) | Phone Number | Email Address | | Effective Date
(If outside of open enrollment) | | | | | | | | Department: 􀂉 ADM 􀂉 BTS 􀂉 P10 􀂉 P11 􀂉 P12 􀂉 PCA 􀂉 PCT 􀂉 RCL | | | | | Benefit Election | Section 125 Benefit | Yes/No | Annual Election | \# of Paychecks | Paycheck Deduction | | --- | --- | --- | --- | --- | | Health Care FSA
Maximum of $3,050 .00 per plan year | 􀂉 Yes
􀂉 No | $ | 12
or | $ | | Day Care FSA
Maximum of $5,000 .00 per plan year
(or $2,500 if you’re married and filing taxes separately) | 􀂉 Yes
􀂉 No | $ | 12
or | $ | | Premium Conversion
The group insurance premiums you pay through your paycheck are automatically deducted pre-tax. Premium contributions toward domestic partner coverage will be deducted post-tax unless they qualify as a tax dependent. | | | | Automatic | Debit Card & Direct Deposit | Navia Debit Card – You may use the card to pay for expenses directly from the funds in your Health Care FSA and/or Day Care FSA. There is no cost for the initial card. The cards are valid for 3 year periods; if you’ve previously received the card then it will be reloaded with your new election. You must provide a valid email address to use the card. | | Automatic | | --- | --- | --- | | Direct Deposit – Reimbursements are electronically deposited into your bank account. If you’ve previously signed up for direct deposit with Navia your information will remain on file and you do not need to complete this section. | 􀂉 Yes 􀂉 Checking Routing \#
􀂉 No 􀂉 Savings Account \# | | Signature | This election form will remain in effect and cannot be revoked or changed during the plan year unless the revocation and new election are on account of and consistent with federal regulations. I understand that Health FSA reimbursements will be available only for qualifying medical care expenses for myself, spouse, and dependents. I also understand that Day Care reimbursements will be available only for qualifying day care expenses. I agree to notify the Employer if I have reason to believe that any expense for which I have obtained reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Employer on demand for any liability it may incur for failure to withhold federal, state or local income tax or Social Security tax from any reimbursement I receive of a non-qualifying expense, up to the amount of additional tax actually owed by me. I understand the benefits and I have read the reverse page. I hereby authorize and direct my employer to reduce my salary by the amount necessary to pay for the benefit(s) as shown above for the plan year indicated above. | | | --- | --- | | 􀂉 YES, the above benefits have been explained to me and I elect to participate as indicated | | | 􀂉 NO, the above benefits have been explained to me and I decline participation | | | Employee Signature | Date | | X | | Completed Enrollment Forms must be returned to Peralta CCD Benefits Office 333 East 8th Street, Oakland CA 94606 Please see the reverse side for important information regarding the above benefits Additional Information 􀂃 Premium Conversion o If the enrollment status is marked as ‘AUTOMATIC’, you must notify your employer in writing to decline enrollment in this benefit. Premium Conversion is subject to the change in status rules and is considered an election equal to the amount of your premium deductions. 􀂃 Health Care Flexible Spending Arrangement (“Health Care FSA”)

FAQs

What are the key dates for submitting claims and the grace period?

The Plan Year runs 1/1/2023–12/31/2023 with a grace period through 3/15/2024. The last day to submit claims is 3/31/2024.

What expenses qualify for reimbursement under the Health Care FSA and Day Care FSA?

Health Care FSA reimbursements are limited to qualifying medical care expenses for the employee, spouse, and dependents. Day Care FSA reimbursements cover qualifying day care expenses as described in the Plan document and applicable IRS code.

How does Premium Conversion work and what does “automatic” mean on the form?

Premium Conversion deducts group insurance premiums paid through payroll on a pre-tax basis. If the enrollment status is marked “AUTOMATIC,” the employee must notify the employer in writing to decline enrollment in that benefit.

Sep 19, 2026

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