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Yment delay. *** U U *** Refer to Instructions on reverse side. *** 1. Employee Information Employee s FSA Identification Number Employee s Last Name First MI W Daytime Telephone Number ( Street Address City ) State - Zip Code 2. Employer Information Employer Name FSA Control Number 3. Expense Information Patient s First Name Date of Birth (MM/DD/YYYY) Relationship to Employee Self Spouse Dependent Date(s) of Service (MM/DD/YYYY) From / / Thru / Patient s Firs.

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A flexible spending arrangement (FSA) allows employees to get reimbursed for medical or dependent care benefits from an account they set up with pre-tax dollars. The salary-reduction contributions are not included in your taxable wages reported on Form W-2.

Submit Your Claim in One of These Ways Log in to your account. ... Once you have logged into your account, click Submit Receipt or Claim and select your Reimbursement Option. Follow the step-by-step instructions. Upload digital copies of your itemized receipts (and other documentation if needed).

Box 14 is used to report amounts that don't belong in other boxes on Form W-2. Employers can use it to report additional tax or income information for filing or informational purposes. Some employers use box 14 to report amounts deducted for State Disability Insurance taxes or union dues that may be tax deductible.

Box 14 — Employers can use W-2 box 14 to report information like: A member of the clergy's parsonage allowance and utilities. Any charitable contribution made through payroll deductions. Educational assistance payments. Health insurance premium deductions. Nontaxable income. State disability insurance taxes withheld.

A Flex Plan functions much like a personal expense account. You set aside money from each pay check PRE-TAX to pay for eligible expenses. This reduces the amount you pay in FICA, Medicare, other payroll taxes, and increases your take home pay!

You aren't taxed on the amounts you or your employer contributes to the FSA. However, you must include in your income any contributions your employer makes for your long-term medical care insurance. You usually forfeit money you contribute that you don't spend by the end of the plan year.

A flexible spending account (FSA) allows employees to be reimbursed for medical or dependent care benefits from an account they set up with pretax dollars. The salary-reduction contributions aren't included in taxable wages reported on Form W-2 and they are not eligible as tax deductions.

A flexible spending arrangement (FSA) allows employees to get reimbursed for medical or dependent care benefits from an account they set up with pre-tax dollars. The salary-reduction contributions are not included in your taxable wages reported on Form W-2.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232