Tri star systems fsa claim form 2026

1. Click ‘Get Form’ to open the tri star systems FSA claim form in the editor.
2. In Part 1, fill in your personal details including your Social Security Number or Account Number, last name, first name, address, city, state, zip code, employer name, and email. Ensure all information is accurate to avoid delays.
3. If you are claiming for dependent care expenses, proceed to Part 2. Enter the dependent's name, phone number, age, service start and end dates. Include the provider's Tax ID/SSN and name along with the amount claimed.
4. For health care claims in Part 3, provide the patient’s name and service date. Describe the service provided and include the provider's name. Attach valid receipts as specified.
5. Finally, complete Part 4 by signing and dating the acknowledgment section to certify that all information is correct and complete.

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