Instructions

Please complete the below form to make changes to the limits for an existing benefit administered by Benefit Resource. If you would like to add or change a plan, please reach out to your Assigned Representative. 
Reference Information on the Limits for 2022
IRS has released indexed limits for 2022. In order to take advantage of the expanded limits, plan sponsors must amend their plan to reflect the new limit. 

Plan Type 2022 Plan Year 2021 Plan Year
Health FSA / Limited FSA  $2,850 $2,750
FSA Rollover Limits for 2022 into 2023 $570 $550*
Dependent Care FSA  $5,000 $10,500**

* FSA Relief passed December 2020 allowed for a temporary increase to roll the entire balance in 2021. 
**ARPA passed in March 2021 allowed for a temporary increase to $10,500. Without legislative action, plans will revert back to the $5,000 limit in 2022. 

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1. Authorization to change 2022 election limit for Health FSA  and/or Limited FSA
I, on behalf of the company listed below, authorize Benefit Resource, LLC to make the following change to our 2022 Plan Year election limit for a Health FSA and/or Limited FSA: 

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2. Authorization to change eligible rollover amount from Health FSA and/or Limited FSA.
I, on behalf of the company listed below, authorize Benefit Resource, LLC to make the following change to the eligible rollover amount for the 2022 Plan Year from a Health FSA and/or Limited FSA.

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3. Request for additional changes

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4. Company / Plan Sponsor Information

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