Flexible Spending Account Forms and Documents

Flexible Spending Account Enrollment Form

Change in Status Request Forms

  • Changes in deduction amounts will be effective the first day of the month following the receipt of the form. 
  • Please note that decreases cannot be less than amounts for which you have already received reimbursement from the plan.
  • Unfortunately, the IRS does not permit a refund of pre-tax dollars that are contributed to an FSA.

To change your FSA contributions, complete and return a Request for Change in Status form:

Other Forms

Flexible Spending Account Books

More Information on Flexible Spending Accounts