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Flexible Spending Accounts

Flexible Spending Account (FSA). A FSA allows you to pay certain Health Care and/or Dependent Care expenses with pre-tax money. Money is diverted out of each of your paychecks on a pre-tax basis and put into a Health Care Reimbursement Account and/or a Dependent Care Assistance Account.

Health and Dental Insurance Premium Offset: You may have your health and dental premiums deducted from your pay check on a pre-tax basis. This will reduce your gross pay and as such your tax liability.

ENROLLMENT FORMS-These enrollment forms are for the full Plan Year beginning 7/1/2020 through 6/30/2021.

These Flexilble Enrollment Forms are used to enroll in the Health Care Reimbursement Account, Dependent Care Assistant Account, or elect your health and dental premiums to be deducted pre-tax.

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.