Claim Forms

Before you submit a claim, review the Claim Filing Requirements to insure you understand what is required so that you can be sure to get your money back fast. Remember you can submit a completely paperless FSA claim form online by clicking Online Access/Account Detail above and then selecting Participant.

Claim FormPDFWord
General FSA Claim FormPDFMicrosoft Word
HRA Claim FormPDFMicrosoft Word
Mass Transit/Van-Pooling/ParkingPDFMicrosoft Word
State of Arizona EmployeesPDFMicrosoft Word
Arizona Board of Regents FSA Claim FormPDFMicrosoft Word
Arlington County FSA Claim FormPDFMicrosoft Word
State of California FlexElectPDF 
State of California Pre-Tax ParkingPDF 
California State UniversityPDFMicrosoft Word
City County Insurance Services (CIS)PDFMicrosoft Word
North Dakota RetireesPDFMicrosoft Word
San Diego County EmployeesPDFMicrosoft Word
State of Colorado EmployeesPDFMicrosoft Word
State of Delaware EmployeesPDFMicrosoft Word
State of Iowa EmployeesPDFMicrosoft Word
Iowa State University EmployeesPDFMicrosoft Word
State of Missouri EmployeesPDFMicrosoft Word
State of Nebraska EmployeesPDFMicrosoft Word
University of Colorado EmployeesPDFMicrosoft Word
Vassar HRA Claim FormPDF