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Notification of Terminations to the 125 Plan

Notification of Terminations to the 125 Plan

After filling out form, please scroll to the bottom and hit Submit.

    Employer

    Date (MM/DD/YY)

    Prepared By:

    Work Phone

    Employee 1

    Name and last 4 digits of SS#

    Termination Date

    Last Pay Period withheld:

    YTD Total

    Benefits Terminated: (Example):FSA Medical Group Help

    Employee 2

    Name and last 4 digits of SS#

    Termination Date

    Last Pay Period withheld:

    YTD Total

    Benefits Terminated: (Example):FSA Medical Group Help

    Employee 3

    Name and last 4 digits of SS#

    Termination Date

    Last Pay Period withheld:

    YTD Total

    Benefits Terminated: (Example):FSA Medical Group Help

    Employee 4

    Name and last 4 digits of SS#

    Termination Date

    Last Pay Period withheld:

    YTD Total

    Benefits Terminated: (Example):FSA Medical Group Help

    Please notify us immediately of all Terminations. It's very important that we know if the employee was on FSA Medical or Dependent Care Care Assistance program so that a reimbursement check does not go out unaccounted for.