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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