2022 Flexible Spending Accounts Election 

Form The Federal Judiciary Benefits Program

NAME: ___________________________ EMPLOYEE ID: ____________ DATE OF BIRTH: ________ 

ADDRESS: ____________________________________ CITY: __________________ STATE: _____ ZIP CODE: ________

EMAIL: _______________________________________________ PHONE: __________________ 

B. Qualified Life Event Code

EVENT CODE: Open Season elections New Hire elections

HCRA – Health Care Reimbursement Account Election 

Election to Participate - I hereby elect to participate in the HCRA. I elect to contribute $________________ for the current plan year.

LPHCRA – Limited Purpose Health Care Reimbursement Account Election 

Election to Participate - I hereby elect to participate in the LPHCRA. I elect to contribute $________________ for the current plan year.

DCRA – Dependent Care Reimbursement Account Election 

Election to Participate - I hereby elect to participate in the DCRA. I elect to contribute $________________ for the current plan year.

• I agree that my compensation will be reduced by the amount I have elected under the Flexible Benefit Program, continuing for each pay period until this agreement is

amended or terminated for the current plan year. 

• I understand that my election is for the 2022 Plan Year beginning January 1 and ending December 31. My deduction per pay period is my annual election divided

by the number of remaining pay periods in the Plan Year.

• I understand that I cannot change or revoke any of these elections before January 1 of the next plan year, unless I experience a Qualified Life Event (e.g., marriage, 

divorce, birth or adoption of a child, death of a spouse or child, termination or commencement of employment by my spouse or other such events allowed under the

Internal Revenue Code) and the election change is caused by, and consistent with, the QLE.

• I understand that any pre-tax elections I have made will reduce my compensation for Social Security tax purposes. This means that my Social Security benefits could

be decreased.

• I understand that any amount remaining in my Health Care or Limited Purpose Reimbursement Account (HCRA/LPHCRA) and/or my Dependent Care

Reimbursement Account (DCRA) after the end of the Plan Year will be forfeited.

• I understand that if I wish to add, change or continue in one or both Flexible Spending Accounts, I must make an election each year. My election will not carry over

from one plan year to the next.

• My election amount(s) will be noted on my confirmation statement. 

Signature Date 

Effective Date of Coverage: 

Refer to the effective date schedules posted on the JBC site for determination of your effective date of coverage. 

Election Limits:

HCRA - Health Care Reimbursement Account - If you wish to enroll in the HCRA please indicate the amount you wish to contribute for the plan year. 

The maximum allowable annual election is $2,850 and the minimum is $100. 

DCRA - Dependent Care Reimbursement Account - If you wish to enroll in the DCRA, please indicate the amount you wish to contribute for the 

plan year. The maximum allowable annual election is $5,000 (if married and filing taxes separately, the maximum is $2,500) and the minimum is $100. 

A. Personal Information (Please Print)

C. Signature - Please read the following carefully before completing your election: