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Forms and Publications

2015-2016 Tax Reporting FAQ’s

2016 ACA 1095 FAQ’s – FAQ sheet regarding 2016 tax reporting/ACA/1095 forms.

2017-2018 Benefit Enrollment/Change Forms

2017-2018 OEBB-Appeal Form – This form is required if you need to challenge a decision made by OEBB or missed an enrollment deadline.  This form gets returned to OEBB directly, the addresses and numbers are on the form itself.

2017-18 Benefit Enrollment Essentials – Use this guide to find out basic information to help guide you through enrollment.

2017-18-New-Hire-Enrollment-Form – This form is for new hires and newly benefit eligible employees to complete.  This enrolls them in medical, Rx, dental, and vision coverage.  This form is also used to waive coverage as well as designate beneficiaries.  Health and Medical Plans

2017-2018 – Mid-Year Change Form – This form is used for employees that are currently enrolled and need to make a change to their elections (must have a valid QSC) or their beneficiaries.

2017-18 Flex Spending Enrollment Form – This form is to enroll in the Flexible Spending Account plans for both Health Related Expenses as well as Dependent Care Expenses

Wellness Clinic Enrollment Form – This form is used by all benefit eligible employees for initial enrollment.  You only need to complete this form if you are waiving other health benefits.

FSA Change Form (Pacific Source) – This form is for mid-year changes to Dependent Care FSA only. Please return completed form within 30 days of the change. Please note that the form needs to be returned to Human Resources by the 15th of the month for changes to current month pay cycle.


Other Benefits Related Forms

ACH Form – Please return a signed ACH form to Human Resources if your monthly insurance premium will be paid through your bank. This form is usually used by retirees and employees who are on a leave of absence and not receiving a paycheck.

Affidavit-of-Domestic-PartnershipTo add a domestic partner by affidavit to your coverage, you must submit this affidavit

FSA Reimbursement form – This form is to file a claim with PacificSource Administrators to be reimbursed under your FSA plan.  You can also file a claim electronically by using this link as well.

Hire a Spouse Form (fill-able) / Hire a Spouse Form (printable) -This form is needed to confirm or waive eligible dependent coverage continuance after a 4J retiree terminates from the plan due to Medicare eligibility. Please complete this form and submit to 4J Human Resources 30 days prior to retiree coverage ending.


403(b) TSA Salary Reduction form – Licensed and MAPS– Licensed and MAPS employees use this form to enroll in TSA Plan

403(b) TSA Salary Reduction form – Classified  – Classified employees use this form to elect salary deferral to participate in TSA Plan