FSA Forms

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

 

Adobe Reader is required to view and download forms.

get_adobe_reader_002

 

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

i2441--2014_Image

IRS Form 8839

form8839

IRS Form 8839

Instructions for IRS Form 8839

 

Need a form that you do not see? Please contact us for assistance.

 

Adobe Reader is required to view and download forms.

get_adobe_reader_002

 

 

FSA Infomation Video


[ Return to Forms Home ]

FSAwoman
FSA Eligible Expenses and Items