2005 fsa form-2026

1. Click ‘Get Form’ to open the 2005 FSA Claim Form in the editor.
2. Begin by completing Part 1, which includes your Employee Information. Fill in your name, Employee ID, date of birth, address, daytime telephone number, and FSA group number.
3. Move to Part 2 for Health Care Expenses. List each expense on a separate line, including the patient’s name, dates of service, type of services (circle MD, RX/OTC, VS, DN, HR), and the request amount.
4. In Part 3 for Dependent Care Expenses, provide the dependent’s name and date of birth. Document the dates of service and attach any required receipts that show costs incurred.
5. Review the Certification for Reimbursement section. Sign and date the form to confirm that all information is accurate and complete.
6. Make a copy of your completed form and any supporting documents for your records before submitting it via mail or fax as instructed.

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