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Get FSA1 2012-2024

Ement, sign and date the form. Make a copy of this form and any documents you send for your records. FSA 3. All reimbursement requests for a plan year made during the following year must be postmarked prior to the filing deadline, which is specified in your plan documents. 4. Mail (or FAX) the form to UnitedHealthcare, FSA Customer Service Center, P.O. Box 981506, El Paso TX, 79998-1506 • Phone: 800-842-2026 • 711 Relay via TRS • FAX: 915-231-1709 Toll Free FAX: 866-262-6354 PART 1 EMP.

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