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9' <br />ii <br />fli <br />I <br />a <br />I <br />I <br />a <br />I <br />I <br />a <br />I <br />a <br />I <br />I <br />I <br />1 <br />9. in order to pay a benefit, the plan must receive a <br />written statement from a third party stating the expense <br />and a written statement from the employee stating the <br />expense is not being reimbursed by another source. <br />10. Forfeitures at the end of the plan year are considered <br />to be part of an "experience gain”. The total <br />experience gain is the total premiums paid over the <br />FSA's total claims reimbursements and reasonable <br />administrative costs. The options for use of any such <br />gains include: <br />- Return them to participants for the past year on an <br />equal basis or weighted to reflect total elections, <br />not forfeited amount, of each participant. <br />Use them to reduce premium costs for the next plan <br />year. I.e., offer $500 worth of benefits for $480 <br />in contributions. <br />11. Special requirements for dependent care FSAs include: <br />e The maximum pre-tax reimbursement is $5,000 per <br />year. <br />e Employees must receive a statement of their <br />dependent care account usage as of each December 31. <br />e Employers must reflect the amount of pre-tax <br />contributions for the year on the employee's W-2 <br />forms. <br />e Child care reimbursements are only allowed for <br />dependents under age 13. <br />an.