Return DEPENDENT CARE ADVANTAGE ACCOUNT CHANGE IN STATUS FORM Employee NameLast Name First Name Middle Initial Social Security Number:   Home Address Street   City   State: Zip Code: Work Phone:   Home Phone: Department ID: (5-Digit Agency Code)   NYS Department/Agency (Ex: Dept of Health, DOT, Tax & Finance, etc.) IF YOU HAVE A CHILD(REN) ENROLLED IN ONE OF THE NYS NETWORK CHILD CARE CENTERS LISTED ON THE COMPANION SHEET TO THIS FORM, PLEASE ENTER THE CORRESPONDING CODE NUMBER HERE: __________ CHANGE / ENROLLMENT REQUESTED MUST BE SUBMITTED WITHIN 60 DAYS OF EVENT Your expenses will be eligible for reimbursement from the date this form is received by the Family Benefits Program or the date of your change in status event, whichever is later.   TERMINATE ACCOUNT   START NEW ACCOUNT: MY CONTRIBUTION $ ___________ + EMPLOYER CONTRIBUTION* $ ___________ = TOTAL ANNUAL AMOUNT $ ___________ (*SEE COMPANION SHEET)(DO NOT LEAVE BLANK OR PUT $0)   CHANGE EXISTING ACCOUNT: Current Annual Contribution $ _____________________New Annual Contribution $ _____________________ (Including Employer Contribution)(Including Employer Contribution) Your annual contribution will be prorated based upon your deductions to date and the number of payrolls remaining in the plan year. PLEASE INDICATE THE TYPE OF CHANGE IN STATUS INCURRED:    Marriage    Separation or Divorce    Death (Spouse or Dependent)    Birth or Adoption of Child    Beginning or End of Employment (Employee or Spouse)    Dependent Disability    Change in Care Provider    From full-time to part-time employment or vice versa (Employee or Spouse)    Beginning of or return from leave of absence (Employee or Spouse)    Change in work schedule (Employee or Spouse)    Change in custody of dependent    Change in rate paid (Provider initiated)    Dependent reaches age 13        THIS IS TO CERTIFY THAT ON ____/____/________ (DATE OF EVENT), I INCURRED THE CHANGE(S) IN STATUS CHECKED ABOVE, AND THEREFORE WISH TO CHANGE MY PLAN BENEFITS AS INDICATED ABOVE. I UNDERSTAND THAT THE CHANGE REQUESTED MUST BE CONSISTENT WITH THE CHANGE IN EVENT. NOTE: The IRS allows only the above changes in status and requires that you maintain legal documentation of the changes in your personal records. Examples of documentation include marriage, birth, or death certificates; divorce decrees; notices of legal separation; proof of change in spouse's employment; or adoption papers. I HAVE READ THE DEPENDENT CARE ADVANTAGE ACCOUNT ENROLLMENT MATERIAL DISTRIBUTED TO ME. I UNDERSTAND THAT MY DEPENDENT CARE ELECTION WILL BE IN EFFECT THROUGHOUT THE CALENDAR YEAR, UNLESS I EXPERIENCE A CHANGE IN FAMILY STATUS THAT WOULD ALLOW ME TO ADJUST MY COVERAGE. I FURTHER UNDERSTAND THAT BY COMPLETING AND SIGNING THIS FORM, I AUTHORIZE THE STATE TO DEDUCT THE DCAACCOUNT CONTRIBUTIONS IN PRE-TAX DOLLARS FROM MY PAYCHECK, WHICH CAN ONLY BE USED TO REIMBURSE ME FOR QUALIFIED DEPENDENT CARE EXPENSES INCURRED DURING THE CALENDAR YEAR AND WHICH WILL BE FORFEITED IF NOT USED FOR THAT YEAR. I ALSO UNDERSTAND THAT REIMBURSEMENTS CANNOT EXCEED AMOUNTS CREDITED TO MY DCAACCOUNT. EMPLOYEE SIGNATURE _____________________________________________ DATE ____/____/______ Mail completed form to: Family Benefits Program DCAAccount 55 Elk Street, Suite 301-C Albany, NY 12210-2331 NYS FLEX SPENDING ACCOUNT A STATE EMPLOYEE BENEFIT THAT PUTS MONEY IN YOUR POCKET 1-800-358-7202 (THEN PRESS 2) Office Use Only Date Received by FBP _____________________ FBP Authorization ________________________ New Biweekly Deduction Amt. _______________ Number of Remaining Paychecks ____________ Pay Basis Code __________________________ 2005