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Click ‘Get Form’ to open the FSA Enrollment Form in our platform.
Begin by filling out the Employee Information section. Enter your last name, first name, SSN or Employee ID, home address, date of birth, phone number, email address, effective date, and department name. Ensure all information is legible for proper enrollment.
In the Benefit Elections section, indicate your choices for Health Care FSA and Day Care FSA by selecting 'Yes' or 'No'. If you choose 'Yes', enter your annual election amounts within the specified limits.
For Premium Conversion, select the number of paychecks for deductions and input the corresponding amounts. This ensures that your contributions are deducted pre-tax.
If opting for a Navia Debit Card or Direct Deposit, provide your bank account details as required. Make sure to check the box indicating whether you want these services.
Finally, review the Signature section. Confirm your understanding of the benefits and sign with the date to complete your enrollment.

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Versions	Form popularity	Fillable & printable
2021	4.6 Satisfied (31 Votes)
2020	4.7 Satisfied (27 Votes)

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What documentation do I need for FSA?

Remember, to be accepted for a claim, youll need one of the two accepted forms of paperwork: an itemized receipt, or an Explanation of Benefits (EOB) form (which is typically used for eligible medical services).

How to submit a FSA form?

Online Submission Log in to the FSAFEDS app using the same username and password as your online account. Select whether to submit a claim or pay a provider. Follow the prompts to enter claims details. Take photos of your itemized receipts (and other documentation if needed) or upload from your mobile device.

Do I need to file FSA?

Box 10 on your W-2 form should indicate the total annual amount of your Dependent Care FSA deductions. When completing your tax return, you will need to attach a Child and Dependent Care Expenses form (Form 2441 for a 1040 return; Schedule A for a 1040A return). You should contact a tax preparer for more details.

Do I get a form for FSA?

The funds in your Medical and Dependent Care FSA are deposited pre-tax and the amount is deducted from your Annual Gross Income. This will be represented on the W-2 you receive from your Employer for tax reporting. There are no additional tax forms issued for the FSA plans.