Flexible Spending Account (FSA)

Forms & Documents

Forms

Enrollment Form
Claim Form (fill-in) (Claim Sample)
Claim Form (print version)
Change Form
Worksheet - Health Benefits
Worksheet - Dependent Care

Documents

Summary Plan Description
Plan Document
FSA Brochure

This Web site describes the benefits in effect on January 1, 2009. The site does not meet the requirements of a summary plan description and is not intended to serve as one. If there are discrepancies between this information and any of the plan documents or State of Iowa policies, the plan documents or State of Iowa policies will govern in all cases.


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