Human Resources

Flexible Spending Accounts (FSA)

Forms & Documents

Forms

Claim Form (fill-in) (Claim Sample)
Claim Form (print version)
Change Form (use for change in status )
Prepayment form (for retirees)
Worksheet - Health Benefits
Worksheet - Dependent Care

Documents

FSA Brochure
Summary Plan Description
Plan Document

This website describes the benefits in effect on January 1, 2012. This 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. The benefits described on this website are subject to change. Nothing herein shall be construed as a guarantee of future benefits.


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