Get 2012 Flexible Spending Account

Filling out the 2012 Flexible Spending Account form online can help you manage your medical and dependent care expenses efficiently. This guide will provide you with step-by-step instructions to ensure that you complete the form accurately and effectively.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to obtain the document and open it in your preferred editor.
2. Begin by entering your full name in the designated box, ensuring to include your last name followed by your first and middle names.
3. Input the last four digits of your Social Security Number in the specified field.
4. Provide your employee number by locating it on your employment documents and entering it in the appropriate section.
5. Fill in your address, including the street number and name, city, state, and zip code.
6. Select your gender by marking either the Male or Female option.
7. Enter your date of birth in the required format.
8. Specify your plan number as indicated in your benefit materials.
9. Insert your email address to ensure you receive important communications regarding your Flexible Spending Account.
10. Complete your home phone number for contact purposes.
11. Indicate your intention to participate in the Flexible Spending Account by checking the appropriate box.
12. Calculate and enter your total annual election amount for both health care and dependent care accounts, ensuring it is within the allowed minimum and maximum limits.
13. Acknowledge your understanding of the terms by reviewing the summary of the risks and conditions associated with your election.
14. Sign the form to certify that you have not and will not be reimbursed for the same expenses from another plan.
15. Date your signature, ensuring this is completed prior to the effective date of the plan year.
16. For those opting for direct deposit, complete the Direct Deposit Authorization Form section, including all banking details and signatures.
17. Finally, save your changes, and download, print, or share the completed form as needed.

Take control of your healthcare expenses—complete your documents online today!