The Pension Boards - PBUCC - Flexible Spending Account Forms

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We recently updated our forms and applications. Please select the link for the applicable benefits in which you want to enroll and complete the application.

Election Forms

To enroll in the Flexible Spending Account plan, please complete the Flexible Benefit Plan Election & Salary Redirection Agreement Form. - *For enrollment period October 14- November 14 of every Plan Year *

FSA Change in Status Form *

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