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Authorization for Pre-Tax Payroll Reduction Enrollment 2026
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- Click ‘Get Form’ to open the Authorization for Pre-Tax Payroll Reduction Enrollment in our editor.
- Begin by filling out the 'Personal Information' section. Enter your name, employer, mailing address, city, state, zip code, Social Security Number (SSN), email, daytime phone number, and date of birth.
- Next, move to the 'Payroll Information' section. Indicate how often you are paid by selecting one of the options: Weekly, Bi-Weekly, Monthly, Semi-Monthly, or Other. If applicable, specify if you are a Municipal or School Employee.
- For Flexible Spending Accounts (FSA), enter the amount you wish to contribute for the Plan Year in the designated fields. Ensure that your contributions do not exceed IRS limits.
- Complete the 'Direct Deposit Information' section if necessary. Provide your bank details including account type (checking or savings), bank name, routing number, and account number.
- Finally, review and sign the certification statement at the bottom of the form. Make sure to date your signature before submitting.
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Related links
I wish to participate in the Limited Purpose and/or Dependent Care FSA plan and authorize payroll reduction from my salary on a pre-tax basis in the amount(s)
Jan 1, 2020 Current participants must re-enroll each plan year; it is not automatic. Similarly, Dependent Care claims must be submitted each plan year. Read more
May 24, 2026 Ensure accurate payroll deductions (pre/post-tax, imputed income, arrears) with support for retroactive adjustments and reconciliation outputs.