TLC Plan Services - TLC/Tax Liaison Consultants
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Call us at (608) 286-8854 or (608) 833-PLAN [833-7526]
Services offered by TLC Plan Services
At TLC Plan Services, we take care to provide our customers high quality services personalized for their unique needs. We are available 24 hours a day, 7 days a week. Our staff members are professional, courteous and efficient.

We provide a variety of services including:
Flexible Employee Benefits Services Offered by
TLC Plan Services – TLC/Tax Liaison Consultants:

We have had more than 30 years’ experience in dealing with the methods that enhance an employee’s take home pay without increasing the overhead of the employer. This can be done by taking advantage of various sections of the Internal Revenue Code (IRC) and doing so depending on the method of the tax reporting of the employer. Most of our experience has involved what we will call “micro-sized” businesses. The Federal Government defines Small Business as one with less than 500 employees! We stress the work that can be done with a much smaller entity, thus “micro-sized”: anywhere from one employee to much less than 50 employees.

TLC Plan Services is always acting as a consultancy in addressing this subject and can directly administer some of the various plans and also seeks out major Third Party Administrators (TPAs) when needed, to provide the administration. Fees for such administration will vary considerably. TLC handles no employer or employee funds but the other TPAs do handle money in the reimbursement benefit plans. The benefit plans, all designed to reimburse the employee in a tax-free manner (in lieu of W-2 income) are as follows:

1.IRC Section 105: Medical Expenses and Health Insurance Premiums.
2.IRC Section 125: Medical-related Flexible Spending Account.
3.IRC Section 129: Dependent Care Reimbursement.
4.IRC Section 132: Parking, Commuting and Bicycling Reimbursement.
5.IRC Section 62:  Employee Tools Reimbursement.

All of the above plans have different rules (IRS, DOL, ERISA) for tax qualification and administration and TLC provides the consulting to help the business determine how to use any. TLC will also coordinate all advice with the tax, insurance and financial advisors of the business. We assume that we have had some communication with the business owner before the forms below are completed but if not, the various pages can provide us with a fact-finding with your employee make-up and your areas of interest. Ignore the fee calculation – the fees involved will be determined by who and what is being administered.

Description of Page 1: Gives us information about the business and the number of employees who might be eligible for any of the various plans.

Description of Page 2: Gives us selection of the type of benefit plan that is being considered. If TLC does the administration, the fees covering any of the five plans are covered in the Page 1 amounts – $125 for the business plus $50 for each EE. Administration fees for other TPAs will vary.

Description of Page 3: Gives us information about the sources of support that the business relies on. This information is vital to TLC in order to coordinate the implementation of the various plans and the eventual recommendations made.

Please complete as much as possible and send to us before we can make final recommendations. We might be completing all of this on the phone. Upon implementation of a plan, TLC will send a 3-ring administrative manual or you will receive administrative materials by the other TPA involved.

_____________________________________________________________________________________
Page 1 TLC FLEXIBLE EMPLOYEE BENEFITS – ADOPTION AGREEMENT
for
[A] I.R.C. Section 105 [Medical Expense Reimbursement Plan]
[B] I.R.C. Section 125 [Flexible Medical Spending Account]
[C] I.R.C. Section 129 [Dependent Care Reimbursement]
[D] I.R.C. Section 132 [Parking, Commuting, Bicycling Reimbursement]
[E] I.R.C. Section 62  [Employee Tools Reimbursement]

BUSINESS INFO, EE NON-ELIGIBILITY RULES, EMPLOYEE INFO

[1] EMPLOYER BUSINESS NAME: _______________________________________________F.E.I.N. #______________
ADDITIONAL BUSINESS INFO:
________________________________________ ________________________________________
  Employer/Contact Person [individual] Description of Business/Employer
__________________________________________ _____________________________________
  Address-Street/Mailing City/State/ZIP  
Phone #s [with area code] – VOICE/CELL - ________________________________ - FAX - ___________________
E-MAIL - ______________________________________ WEBSITE - _________________________________

[2] FILING STATUS:
[ ] Sole Proprietor [ ] Partnership [ ] Limited Liability Co (LLC) (also mark how taxed} [ ] C-Corporation [ ] S-Corporation
  [ ] 501(c)(_____) Corporation/Organization [ ] Family - For Domestic Employment

[3] NON-ELIGIBLE EMPLOYEES: (check employee "non-eligibility" rules & elect respective maximums)
[XX] Part-time employees working less than _____ hours (5-25) of work per week (average per year).
[XX] Seasonal employees completing less than _____ months (0-7) at work within a year.
[XX] Employees less than _____ years of age (maximum is age 25).
[XX] Current employees completing less than _____ months (0-36) of service. [Note: use 3 months to comply
[XX] Future employees completing less than _____ months (0-36) of service. with PPACA requirements]

Additional information:
Do you have non-eligible or other family members involved in the business? ___________
Do you have controlling interest in another business? __________
Have you already used Sec. 105 or Sec. 125 in your business? __________ Currently? ___________
If you are currently using, or have used Sec. 105/125, who is the Administrator? ____________________

[4] ELIGIBLE EMPLOYEES: (list those employees who meet or exceed the above non-eligibility limits)
  ____________NAME_____________ ___WORK E-MAIL____ ____HOME E-MAIL_____
INITIAL FEE:
$ 50.00 ea. EE #1) ______________________________ _____________________ _______________________
$ 50.00 ea. EE #2) ______________________________ _____________________ _______________________
$ 50.00 ea. EE #3) ______________________________ _____________________ _______________________
$ 50.00 ea. EE #4) ______________________________ _____________________ _______________________
$ 50.00 ea. EE #5) ______________________________ _____________________ _______________________
$ 125.00 Annual Business fee (future employees, $50 enrollment) (If this is a short year, all of the fees will be proportionate.)
$ ______** THIS IS A 12-MONTH FEE - IF CURRENT YEAR IS A PARTIAL YEAR, IT IS SHOWN BELOW:
$ ______** IF AN AMOUNT IS SHOWN HERE IT IS FOR A PARTIAL YEAR (payable to: TLC PLAN SERVICES)  
  ====== *** Photo-copy & use additional page if you have additional eligible employees.

[5] The undersigned employer executes this agreement on the ____ day of ______________, 20____-- the plan start date shall be _____/_____/20____, except for uninsured [OOP] medical expenses which is the signing date.

AUTHORIZED EMPLOYER SIGNATURE:                                                                                                            WHO REFERRED YOU?  
                                                                                                                                               Person/Group: ______________________________
/S/ ___________________________                                                                                          Phones/e-mail: ______________________________



​__________________________________________________________________________________________________________________________________
Page 2
EMPLOYEE please sign: ________________________________ I have reviewed this form

(when benefit sections are completed-boxes checked, pages 2 & 3 are given to each ELIGIBLE employee) BENEFITS:
[A] [__] I.R.C. SECTION 105 [Medical Expense Reimbursement Plan]

[A1] AVAILABLE BENEFITS (check the benefits available to the eligible employees)
  (These benefits are included as part of the employee’s total “compensation”, but not on the W-2)

[A2] Employee & Family [insurance premiums, sponsored by employer or not sponsored by employer or directly paid by employer or reimbursed]:
Medical or Medical-Related Health Insurance Premiums: Limit of Premium Reimbursement = $_______ per month. [N/A if actual amount]
[__] Medical [__] Dental [__] Vision [__] Cancer [__] Long Term Care [__] Accident Expense        
[__] Health Savings Account: Annual Limit = $_______ (use "MAX" if limit is legal maximum this year or future year)

[A3] Employee & Family [non-insured medical-related] Expense Reimbursement:
(All items included in IRS Publication 502, EXCEPT insurance premiums & HSAs which are included in the premium section above)
[__] Annual Limit: $_________ 3 choices: [1] "PPACA-required"; [2] “$ amount”; [3] "Sec.125 FSA”; [4] "none/no benefit".
Note: Option [1] used if 1 EE; [2] used for 2-5 EEs; [3] used if 2 or more EEs & setting up FSA; [4] if POP-prem. only plan

A3 special note: The “PPACA-required” amount is basically unlimited & should usually be used only for a 1-5 EE plan, usually family members and closely-working EEs. If there are 2 or more eligible employees, a companion Sec. 125/FSA plan can be used [see separate companion plan form]. TLC will charge no additional fees for “companion” plans.

[A4] [__] EE & Family Medical Mileage: (round-trip mileage to & from medical & treatment locations)
Including trips to Physician/Clinic, Hospital, Dental/Vision/Mental/Chiropractic/Holistic/Therapy Care, Pharmacy, etc.

[A5] Employee Only Premiums: [__] Disability Income Ins. [__] Term Life Insurance, up to $50,000 coverage

[B] [__] I.R.C. SECTION 125 [Flexible Medical Spending Account]

[B1] Flexible Spending Account under Sec. 125 Plan Document [__] Annual Limit: $__________
(Max = $2550 in 2015, with a $500 carry-over allowance) (if this option chosen, then each employee will submit form shown below)

[B2] [__] Medical Mileage also included: (round-trip mileage to & from medical-related & treatment locations)

[__] YOU ARE AN ELIGIBLE EMPLOYEE FOR THE SEC. 125/FLEXIBLE SPENDING ACCOUNT
PLEASE COMPLETE THE FOLLOWING & SUBMIT TO YOUR EMPLOYER.

NAME: ____________________________________ SOC. SEC. # _______________
                please print  
PHONE: ____________________ EMAIL: __________________________

WHAT IS THE MONTHLY AMOUNT YOU WISH TO PUT INTO YOUR FSA?
REIMBURSEMENT IS MADE WHEN EXPENSE PROOF IS SUBMITTED

$__________ SIGNED: ________________________________ DATE: __________
Annual limit is $2,550 for 2015 with $500 carry-over – account is held & will be paid by your employer.

[C] [__] I.R.C. SEC. 129 [Dependent Care Reimbursement Plan]
[__] YOU ARE AN ELIGIBLE EMPLOYEE FOR THE SEC. 129/DEPENDENT CARE PLAN
IF YOU WISH TO PARTICIPATE PLEASE INITIAL _______ & FORMS WILL BE PROVIDED

[D][__] I.R.C. SEC. 132 [Parking, Commuting, Bicycling Reimbursement]
[__] YOU ARE AN ELIGIBLE EMPLOYEE FOR THE SEC. 132/”GET-TO-WORK” PLAN
IF YOU WISH TO PARTICIPATE PLEASE INITIAL _______ & FORMS WILL BE PROVIDED

[E] [__] I.R.C. Section 62 [Employee Tools Reimbursement]
[__] YOU ARE AN ELIGIBLE EMPLOYEE FOR THE SEC. 62/EMPLOYEE TOOL EXPENSE PLAN
IF YOU WISH TO PARTICIPATE PLEASE INITIAL _______ & FORMS WILL BE PROVIDED

Please return this form to your employer, or send to
TLC Plan Services – 902 N High Point Rd #353, Madison, WI 53717
& contact – (608) 286-8854 or (608) 833-7526 – tlcplan@outlook.com with any questions (24/7)

_________________________________________________________________
Page 3
This page is a self-mailer & information about your other advisors.

EMPLOYEE/EMPLOYER BENEFIT PLAN SUPPORT INFORMATION
Please complete this section for important information.
You may be eligible for a rebate on your administrative fee if you are a part of a “SEG” [Sponsoring Employer Group]. This can be a co-op, association, business group, financial institution such as a credit union, bank, and accounting firm or financial/insurance group.

[A] NAME OF AGRICULTURAL CO-OP/BUSINESS ASSOCIATION TO WHICH YOU BELONG.
  [It can be a financial institution, chamber of commerce, professional association, etc.]

_______________________________________ ___________________________________________
  Organization/Association Business Name Contact Person Name
_______________________________________ ___________________________________________
  Address [street or mailing] City/State/Zip
_______________________________________ ___________________________________________
  Phone Numbers: Toll-free/Voice/Cell/Fax E-Mail/Web Site

[B] NAME OF YOUR TAX PROFESSIONAL OR TAX PREPARER:

_______________________________________ ___________________________________________
  Business Name Contact Person Name
_______________________________________ ___________________________________________
  Address [street or mailing] City/State/Zip
_______________________________________ ___________________________________________
  Phone Numbers: Toll-free/Voice/Cell/Fax E-Mail/Web Site

[C] NAME OF YOUR INSURANCE AGENT &/OR FINANCIAL PLANNER:

_______________________________________ ___________________________________________
  Business Name Contact Person Name
_______________________________________ ___________________________________________
  Address [street or mailing] City/State/Zip
_______________________________________ ___________________________________________
  Phone Numbers: Toll-free/Voice/Cell/Fax E-Mail/Web Site

NOTE: To whom would YOU refer us regarding our services that might help YOUR contacts?
If possible, give phone numbers as well as addresses. We pay referral fees.

YOUR name/address/phone: