Health and Dependent Care Flexible Spending Accounts

Click on the following links for:

Plan Information-Guide to Eligible Health and Dependent Care Flexible Spending
Account Expenses

Claim Form--Complete this form when you have incurred eligible medical expenses.

Direct Deposit Form-Complete this form to have your reimbursed funds deposited
into your Savings or Checking account.

Change in Family Status Form--Complete this form when a change in status has
occurred which affects your FSA Cafeteria Plan election. All changes must be
due to and consistent with the change in status.*

*All requests for changes to benefits must be received within 31 calendar days of the
qualifying event. In the event that the 31st day falls on a weekend or holiday,
(including closed business days), requests must be received on the last working
day prior to your 31st day.

FSA accounts are effective January 1 through December 31, 2008 and expenses
for these accounts must be incurred by December 31, 2008.

The next opportunity to enroll outside of a qualifying family status change will be in
November, 2008, (effective January 1, 2009).

For additional information, please call Employee Beneftis at 804-7232 ext. 350.