Archdiocese of San Francisco Flexible Spending 2025

1. Click ‘Get Form’ to open the Archdiocese of San Francisco Flexible Spending Arrangement Enrollment Form in the editor.
2. Begin by filling out your Employee Information. Ensure you write legibly, including your Last Name, First Name, SSN/Employee ID#, Home Address, Date of Birth, Phone Number, Email Address, Effective Date, and Department Name.
3. In the Benefit Elections section, indicate your choices for Section 125 Benefits by selecting 'Yes' or 'No'. For Health Care FSA and Day Care FSA, specify your annual election amounts within the provided limits.
4. For Premium Conversion, select the number of paychecks from which deductions will be made. Enter the corresponding paycheck deduction amounts.
5. If opting for a Navia Debit Card or Direct Deposit for reimbursements, check 'Yes' and provide your bank account details if necessary.
6. Finally, review the signature section. Confirm your understanding of the benefits and sign with the date before submitting the completed form to your Site Administrator.

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