Flexible Spending Account Forms and Documents

Please note: You may only receive reimbursements for services incurred during periods when you made contributions to your FSA. When contributions end, the PayFlex debit card is inactivated and your account is expired.

Flexible Spending Account Forms

Enrollment Form

Please note: The maximum age for eligible dependent children covered under the Dependent Care FSA has changed from 12 to 13.

Change in Status Request Forms

In December 2020, the IRS issued revised rules for FSAs under the Consolidated Appropriations Act. This notice provides increased flexibility for 2021 Health Care FSA and Dependent Care FSA participants to make midyear changes during the 2021 calendar year.

  • You may only increase or decrease your 2021 annual election once during the plan year without a corresponding change in status event.
  • Changes in deduction amounts will be effective the first day of the month following the receipt of the form. The final deadline for submitting changes to your 2021 FSA deduction amounts is November 2021 with the change effective for December 2021 paychecks.
  • 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 Book

  • 2021 Flexible Spending Accounts - updated March 31, 2021 to include face masks, hand sanitizer and sanitizing wipes as qualified medical expenses if used for the primary purpose of preventing the spread of the COVID-19 coronavirus per IRS Announcement 2021-7.
  • 2022 Flexible Spending Accounts -  effective January 1 - December 31, 2022. Unlike other benefits, IRS rules do not allow FSA enrollments to carry over from year to year. You need to enroll in an FSA each year you wish to participate. Sign up during annual Open Enrollment.

More Information on Flexible Spending Accounts