“Flex Plan” - Flexible Spending Accounts
(Unreimbursed Healthcare and Child/Dependent Care)
Form PR2: Annual Election Form Front
Form PR2b: Annual Election Form Back
Form PR3: Claims Reimbursement Form
Form PR3b: Claims Reimbursement Form Instructions
Form PR4: Request for Transportation Claim Reimbursement Form
Form PR5: Termination Form
Form PR6: Change of Election Form
Form H: How Do You Benefit
Form P: Proof of Payment
Form WS1: Enrollment Worksheet 1 – Unreimbursed Healthcare
Over-the-Counter Examples
Form WS2: Enrollment Worksheet 2 – Child/Dependent Care
Form WS3: Enrollment Worksheet 3 – Healthcare Premiums
Form DDA: Direct Deposit Authorization
“TFA Plan” - Transportation Fringe Accounts
(Mass Transit and Parking Expenses)
Form PR7: Transportation Fringe Account Election Form
Form PR8: Transportation Fringe Account Reimbursement Form
Form PR8b: Transportation Fringe Account Reimbursement Form Instructions
Form H: How Do You Benefit
Form DDA: Direct Deposit Authorization
“HRA Plan” - Health Reimbursement Accounts
Form PR3hra: HRA Account Reimbursement Form
Form PR3bhra: HRA Account Reimbursement Instructions
Over-the-Counter Examples
Form DDA: Direct Deposit Authorization
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