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Get Asi Flex Oregon

Print Form Clear Form Fax to ASIFlex 877 879-9038 No Cover Page Required STATE OF OREGON FSA CLAIM FORM Documentation Requirements Instructions See back side Page 1 of P Last Name First Name MI Please Print PEBB-assigned ID P 8 digit ID Street Address City State Zip Dependent Care Flexible Spending Account day care babysitting etc. Dependent care expenses must be for a dependent who is incapable of self care or under the age of 13 at the time th.

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