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Flexible Spending Accounts

Health and Dental Insurance Premium Offset:  Reduce your gross pay, and  your tax liability by having your health and dental premiums deducted from your pay on a pre-tax basis.

Flexible Spending Account (FSA). A FSA allows you to pay for certain Health Care and/or Dependent Care expenses with pre-tax money. 

ENROLLMENT FORMS

Enrollment forms for plan year 7/1/2020 through 6/30/2021.

INFORMATION

ADDITIONAL FORMS

  • Direct Deposit Authorization Form
    Form used to request that your reimbursements for your Health Care Reimbursement Account or Dependent Care Assistant account be directly deposited to your specified checking or savings account. 
     
  • Participant Status/Change Form
    If you have a qualifying event during the calendar year; such as marriage/divorce, etc. and need to change your flexible benefit contributions complete this form and send it to HR; Attn: Benefits.
     
  • Reimbursement Request Form
    Claim Form to request reimbursement from your Health Care Reimbursement Account or your Dependent Care Assistance Account.
     
  • Physician Statement Form
    If you have an existing disease, have your doctor fill this form.