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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 that 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. Acrobat Reader can be downloaded for free.



View Sample Claim & Documentation

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General FSA Claim Form Fillable PDF Word Document
State of Arizona employees Fillable PDF Word Document
Arizona Board of Regents employees Fillable PDF Word Document
California Rural Health Care Equity  Fillable 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) Fillable PDF Word Document
State of Missouri employees Fillable PDF Word Document
State of Montana employees Fillable PDF Word Document
State of Nebraska 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 Word Document
HRA/FSA Claim Forms (for use only if you are an HRA participant) PDF