Payflex Reimbursement Accounts Enrollment Form - Amazon S3 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Employer Use Only section, including your Employer ID Number and selecting whether this is a re-enrollment, new enrollment, or change.
3. In Section A, Personal Information, print clearly and complete each field: Employer Name, Employee First Name, MI, Last Name, Social Security Number, Street Address, City, State, ZIP Code, Email, Date of Birth, and Date of Hire.
4. Move to Section B for Election Information. Check the box indicating your participation choice and fill in the amounts for Health Care FSA and Dependent Care FSA as applicable.
5. Review the statements provided at the end of Section B carefully before signing. Ensure you understand the implications of your election.
6. If opting for direct deposit in Section C, authorize PayFlex Systems USA by providing a voided check or savings deposit slip.
7. Finally, sign and date the form to complete your submission.

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