Dependent Care Flexible Spending Account Application
I have read and agree with
terms
and conditions.
I Agree
I Disagree
*
Employer
*
SS #:
*
E-mail
*
Last name:
*
First Name:
*
Address
:
*
City
*
State
*
Zip
*
Home Phone:
*
Work Phone
Spouse's Name
Spouse's Employer
*
Dependent Name
*
Birth Date
*
Provider
Phone
*
Provider Name
*
Provider Address
*
Provider City
*
State
*
Zip
EIN/SS#
*
Pay my provider
per
Select One
week
month
Payment method
Select One
Direct Deposit
Mail Check
Reimburse Me
2nd Dependent
Birth Date
Provider
Phone
Provider Name
Provider Address
Provider City
State
Zip
EIN/SS#
Pay my provider
per
Select One
week
month
Payment method
Select One
Direct Deposit
Mail Check
Reimburse Me
I am paid
Select One
Weekly
Biweekly
Semimonthly
Monthly
I elect to participate and designate to redirect per payperiod
pre-tax
I elect to redirect per payperiod
post-tax - if my employer allows
Sign and Date
Please Print the form and fax to 800-449-7501