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FORMS can be printed, downloaded, completed and faxed or mailed back to us. Address and fax information is provided on each form.PDF files require Adobe Reader for viewing. Adobe Reader can be downloaded for free at: http://www.adobe.com/products/acrobat/readstep2.html

FSA-Flex Spending Account New Enrollee General Information:

File: New Participant Welcome to FSA-Healthcare Information:
File: New Participant Welcome to FSA-Dependent Care Information:

 

FSA-Flex Spending Account ENROLLMENT Forms:

File: FSA-Enrollment-Authorization Form                        (This is a generic form, call CPA Inc if you need information on your plan specs):
File: FSA-City of Boston Enrollment-Authorization Form       (For OPEN Enrollment Use Only):     
FileFSA-City of Boston Employee Change of Status Form (For Qualifying changes/New Hire Form):

FSA-Flex Spending Accounts CLAIM Forms:

File: FSA-Medical Claim Reimbursement Form:
File: FSA-Dependent Care Claim/Certification Form:

TRANSPORTATION & PARKING PLANS CLAIM Form:

File: Qualified Transportation and Parking Claim     Form:

FSA-Flex Spending Accounts MISCELLANEOUS Forms:

File: Direct Deposit Sign-up Form:
FileFSA-Over-the-Counter No longer allowed  without prescription:
FileFSA-Required Physician's Letter:
FileFSA-Eligible Expenses List:
FileFSA-Employee Change of Status Form:

HRA-Reimbursement Forms:   (Not for use for FSA FLEX plans):

File: Direct Deposit Sign-up Form:
File: HRA   Generic - Claim Reimbursement Form:
File: HRA- Town of Ashland         (custom)                     Claim Reimbursement Form:    
File: HRA- Town of Wellesley     (custom)                       Claim Reimbursement Form
  

POP-Premium Only Plan Account Forms (Not for use for FSA FLEX plans):

File: POP-Section 125 Enrollment-Authorization Form:

 

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