FCF Benefits and Administration
Family Status Change Form

Print this document and mail to:

FCF Benefits & Administration
c/o Ron Wright
2494 E. Kays Creek Dr.
Layton, UT 84040


If you experience a change in family status, you will have 30 days following the change to make any
revisions to your participation in the Section 125 Plan. You will not be able to change your
participation after that 30-day period until the next open enrollment.

Please fill in the date the change in family status occurred, and mark the box next to the change in
family status you have experienced. Attach documentation of the change (such as a birth certificate,
marriage license, etc.), and sign and date the form. Please return the completed form within 30
days of the change to your Human Resources Department.

Date of change in family status:____________________________
Effective for the Payroll Date beginning:______________________


Your marriage

Your divorce or legal separation

Death of a spouse or dependent

Birth or adoption of a dependent

Termination or commencement of your spouse's employment

Change from full-time to part-time employment for you or your spouse

Commencement of an unpaid leave of absence for you or your spouse

Change in dependent care provider

Significant change in your group health coverage or your spouse's group health
coverage attributable to your spouse's employment

Change  my Medical Expense witholdings from: $_______ per payroll to:$________

            Change my Day Care witholdings from: $_______ per payroll to:$________

*Payrolls Remaining in Plan Year : _______________

Employee Name:____________________________________ SS#:_________________


Employee Signature: __________________________________ Date: _______________

Human Resources Signature: ____________________________ Date: _______________