Dayton Service Center - Forms & Resources

Client Resources

Participant Resources

Enrollment Materials

• Section 125 Flexible Benefit Plan - Enrollment Form/Direct Deposit Authorization
• Flexible Spending Account (FSA) - Benefit Election Change Form
• Section 125 Flexible Benefit Plan Enrollment Form
• Request for Reimbursement Form
• FSA Worksheet
• FSA or HRA Employee Status Change Form

Enrollment Materials

• Authorization to Release Protected Health Information
• Flex Worksheet
• Flexible Spending Account (FSA) or Health Reimbursement Arrangement (HRA) - Direct Deposit Authorization
• Flexible Spending Account (FSA) - Benefit Election Change Form
• Section 125 Flexible Benefit Plan Enrollment Form/Direct Deposit Authorization
• Flexible Spending Account (FSA) or Health Reimbursement Arrangement (HRA)- Employee Status Change Form
• Request for Reimbursement Form