Claim Forms

Please Use the General FSA Claim Form only if you do not see your employer listed below.  Some employers require specific language on the claim form and, if the wrong form is utilized, claim processing may be delayed.

Please note: If you are using Acrobat Version 4, the PDF form will display some odd numbers in the dollar amount column.  To eliminate these numbers, use the Get Adobe Reader link below to update to the newest version.  There is no cost for upgrading to the newest version of Acrobat Reader.

	Get Adobe Acrobat	Get Microsoft Word Viewer
General FSA Claim Form	FIllable PDF	Word Document
State of Arizona Employees	FIllable PDF	Word Document
Arizona Board of Regents	FIllable PDF	Word Document
California RHCEP	PDF
State of California: Pre-tax Parking	FIllable PDF	Word Document
California State University	FIllable PDF	Word Document
City County Insurance Services (CIS), OR	FIllable PDF	Word Document
State of Colorado Employees	FIllable PDF	Word Document
State of Delaware Employees	Fillable PDF	Word Document
State of Iowa Employees	FIllable PDF	Word Document
State of Kansas (KanElect) Employees	FIllable PDF	Word Document
State of Missouri Employees (MOCafe)	FIllable PDF	Word Document
State of Montana Employees	FIllable PDF	Word Document
State of Nebraska Employees	FIllable PDF	Word Document
State of Oregon Employees	Fillable PDF	Word Document
State of Washington Employees	FIllable PDF	Word Document
University of Colorado Employees	FIllable PDF	Word Document
University of Kentucky/KCTCS Employees	FIllable PDF	Word Document
University of Nevada Employees	FIllable PDF	Word Document
Mass Transit/Van-Pooling/Parking	PDF
HRA/FSA Claim Forms (for use only if you are an HRA participant)	PDF