MOCafe Change Request form

Missouri State Employees’ Cafeteria Plan Change Form

Participant Information

Name (Last, First, MI)

Social Security Number

Agency/Org or University

Name is required.

Street Address

City

State

Zip

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Date of Status Change Event

Daytime Phone Number

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Check this box if this is a new address.

Change of Status Events: Please select all status change events that have occurred in the last 60 days:

Death of spouse/dependent

Gain/Loss of dependent due to age, military status, marriage, divorce, etc

Divorce finalized

Gain/Loss of eligibility and coverage under Medicare/Medicaid

Marriage

Court order (health coverage not your responsibility)

Birth/Adoption

Court order (requiring health coverage)

Residence change

Begin FMLA (Complete Section D)

Employment change of your spouse/dependent

End FMLA

New dependent care provider

Your employment ends or you retire (Complete Section C)

Dependent care rate change

Section A

Current Per Paycheck Deduction

New Per Check Deduction

Health Insurance*

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Dental Insurance*

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Vision Insurance*

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* No entry needed if this is a change to an existing rate already pre-tax through SAMII for MCHCP coverage.

Section B

New Annual Total

New Per Check Amount

Health Care FSA

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Dependent Care FSA

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Section D: FMLA beginning

I authorize to prepay for Health Care Flexible Spending Account (HCFSA)

coverage through

totaling $

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on my paycheck dated

I will pay direct to MO Cafeteria Plan before each pay day.

Make checks payable to: MO Cafeteria Plan

Mail checks to: PO Box 6044, Columbia, MO 65205-6044

Coverage is stopped if payment is not received by pay date

When I return to work, I elect to pay:

a total of $

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for HCFSA coverage through

on the paycheck I receive on

HCFSA coverage is stopped if payment is not received by this pay date.

Please stop my HCFSA coverage while I’m on unpaid FMLA leave. I understand that, if I want to, I can start my coverage within 60 days of returning to work (only at the same amount per check).

By checking this box, I affirm that all details I have filled out in this form are accurate and complete.

Please check this option to continue.

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