skip to main content

Participant Forms

Commuter

Commuter Parking - Claim Form
Bicycle Expense - Reimbursement Request

Flexible Spending Accounts

Flexible Spending Accounts & Commuter - Claim Form
Flexible Spending Accounts - Claim Form
Flexible Spending Accounts - Claim Form - Spanish
Limited Purpose FSA - Claim Form

Dependent Care Assistance Plan

Dependent Care Eligible Expense Table
Receipt for Dependent Care Services
Automatic Dependent Care Claim Form
W10 Form to Request Dependent Care Provider's Tax ID
2441 Dependent Care Expense Form
2441 Instructions

Health Reimbursement Arrangements

Health Reimbursement Arrangement (HRA) - Claim Form
Health Reimbursement Arrangement (HRA) - Claim Form - Spanish
Retiree HRA Recurring Premiums - Claim Form
ICHRA - Recurring Premium - Claim Form
ICHRA - Recurring Premium & Medical - Claim Form
EBSA Claim Form
Reproductive Health HRA

Health Savings Accounts - Avidia Bank

Account Closure Form
Authorized Signer
Beneficiary Form
Change Form (including beneficiaries, authorized signer, and demographics)
Check Order
Contribution Change Form (to change per pay period contributions)
Contribution Correction Form
Death Distribution Form
Distribution Reversal Form
Individual Contribution Form (to transfer money to your HSA)
Reactivate Dormant HSA Bank Account
Transfer Form (Transfer Existing HSA Funds to Avidia Bank)
IRS Publication 969
IRS Form 8889
Instructions for Form 8889

Health Savings Account - WealthCare Saver HSA

Account Closure Form
Authorized Signer
Beneficiary Form
Contribution Correction - Change Year
Contribution & Return of Mistaken Distribution Form
Distribution of Excess Contributions
Power of Attorney
Transfer Form
IRS Publication 969
IRS Form 8889
Instructions for Form 8889

Other

Certification of Medical Necessity
Certification of Medical Necessity - Spanish
Repayment for Ineligible Transactions
Direct Deposit Authorization
Direct Deposit Authorization - Spanish
Dependent Card Application
Qualified Status Change Form

ABG Smart Mobile

Participants