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Flexible Spending Account Forms

Election Forms

FSA Enrollment Form - *For enrollment period November 1-30 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