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FSA Limit Increase Request
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
To take advantage of the expanded limits, plan sponsors must amend their plans to reflect the new limit.
Plan Type
2025 Plan Year
2026 Plan Year
Health FSA / Limited FSA
$3,300
$3,400
FSA Rollover Limits for 2024 into 2025
$660
$680
Dependent Care FSA
$5,000
$7,500
If completing this form for a future plan year
before limits are released by the IRS
, you are authorizing BRI to align your plan limits to the maximum limits when released from the IRS.
1.
Please select the plan year limits should apply to.
2025
2026
2.
Authorization to change
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 Plan Year election limit for a Health FSA and/or Limited FSA:
(Required.)
Increase the allowable election limit for a Health FSA / Limited FSA to the statutory limit as released by IRS.
No change to the election limit for Health FSA / Limited FSA Limit
Change election limit for Health FSA / Limited FSA to another specified amount (please specify)
3.
Authorization to change
election limit
for Dependent Care FSA
I, on behalf of the company listed below, authorize Benefit Resource, LLC to make the following change to our Plan Year election limit for a Dependent Care FSA:
(Required.)
Increase the allowable election limit for a Dependent Care FSA to the statutory limit as released by IRS.
No change to the election limit for Dependent Care FSA Limit
Change election limit for Dependent Care FSA to another specified amount (please specify)
4.
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 Plan Year selected above from a Health FSA and/or Limited FSA.
(Required.)
Update the eligible FSA Rollover amount to the Statutory Limit as released by IRS.
I do not wish to make a change to the FSA Rollover limit / we do not use the rollover option.
Change FSA Rollover Limit to another specified amount, not to exceed the statutory limit. Please specify.
5.
Company / Plan Sponsor Information
Contact Name
Company / Plan Sponsor
Email Address
Phone Number
