Cpa125 2026

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4.9 out of 5

43 votes

The document is an authorization form for pre-tax payroll reduction related to Flexible Spending Accounts (FSA) managed by Cafeteria Plan Advisors, Inc. It collects personal and payroll information from employees, allows them to elect contributions for dependent care and medical/dental accounts, and outlines the terms of participation, including eligibility criteria and conditions for fund forfeiture. The form must be returned to Cafeteria Plan Advisors for processing.

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Click ‘Get Form’ to open the cpa125 in the editor.
Begin by filling out the Personal Information section. Enter your Name, Employer, Street Address, City, State, Zip Code, Social Security Number (SSN), Email, and Phone number.
Next, move to the Payroll Information section. Indicate how often you are paid by selecting Weekly, Bi-Weekly, Semi-Monthly, Monthly, or Other. If applicable, check if you are a Municipal Employee or School Employee and provide your Department/Location.
In the Benefits Selected section, choose your desired Flexible Spending Accounts (FSA) options by checking the appropriate boxes. Specify your contribution amounts for both Dependent/Day Care Account and Medical/Dental Care Account within the stated limits.
Complete the Direct Deposit Information if necessary. Select Checking or Savings and provide your Bank Name, Routing Number (9 digits), and Account Number.
Finally, review the Certification section carefully. Sign and date the form to authorize your salary reduction agreement.

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Versions	Form popularity	Fillable & printable
2022	4.3 Satisfied (54 Votes)
2017	4.9 Satisfied (43 Votes)

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Are FSA contributions subject to state taxes?

All of these accounts HRAs, FSAs and HSAs are tax-advantaged, meaning the contributions, or the funds you put into the account, are untaxed. You can put the funds toward eligible expenses for medical, vision and dental care.

What is a 125 medical spending account?

For instance, a section 125 plan or cafeteria plan allows employees to pay qualified medical, dental, vision, or dependent care expenses on a pre-tax basis, which can reduce their taxable income as well as their employers Social Security (FICA) liability, federal income, and unemployment taxes (FUTA), and state

What is Section 125 of the Internal Revenue Code FSA?

A Section 125 plan is the only means by which an employee is permitted to use pre-tax dollars to contribute towards employer sponsored benefits (e.g. health insurance premiums, dental or vision premiums, disability premiums, life insurance, and FSA accounts).

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What income is not taxable in Pennsylvania?

Some types of income are exempt from Pennsylvania state income tax, including child support, alimony, unemployment payments, and some capital gains on the sale of a primary residence. Some deductions are allowed for contributions to educational savings accounts and medical or health savings accounts.

Are FSA contributions taxable in PA?

Note: In Pennsylvania, contributions to Health Care and Limited-Purpose FSAs are exempt from state income tax. Dependent Care FSAs are subject to Pennsylvania state income tax but remain exempt from federal tax.

Do I report FSA contributions on taxes?

If I participated in a Health Care FSA, do I need to report anything on my personal income tax return at the end of the year? No. There are no reporting requirements for Health Care FSAs on your income tax return.

Are employer contributions to FSA taxable?

Amounts contributed are not subject to federal income tax, Social Security tax or Medicare tax. If the plan allows, the employer may also contribute to an employees FSA.

What are the basics of Section 125?

CAFETERIA PLAN BASICS A Section 125 plan provides employees with an opportunity to pay for certain benefits on a pre-tax basis, allowing them to increase their take-home pay. Employers may also make nontaxable contributions to a Section 125 plan for their employees.

Cpa125 2026

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