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Flexible Spending Account Forms

Election Forms

FSA Plan for UCC Ministries Election Form and Compensation Reduction Agreement Form 2022 - For enrollment period of November 1, 2021 – December 27, 2021

Annuity Plan Membership and Other Benefits Form – For enrollment in the FSA plan or other benefit plans outside of open enrollment

Health FSA

FSA Plan for UCC Ministries Medical Care Expense Claim Form

Qualifying Medical Care Expenses Worksheet


Dependent Care FSA

FSA Plan for UCC Ministries Dependent Care Claim Form

Qualifying Dependent Care Expenses Worksheet