FSA Forms

Below are downloadable forms associated with FSA plans.
Click here for instructions on how to submit your claim.

 

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Formulario de pedido de desembolso de reclamo de la Cuenta de Gastos Flexibles

Spanish FSA Claim Form

FSA Direct Deposit
Authorization Form

Direct Deposit Authorization

 

 

IRS Form 2441

IRS Form 2441 Image 2013

 

Instructions Form 2441

IRS Form 2441 Instructions

IRS Form 8839

form8839

Instructions Form 8839

form8839Instructions

 

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FSA Infomation Video


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