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For more information:
FlexBank, Inc.
Local: 937.299.5515
Free: 888.677.8373
1250 West Dorothy Lane
Suite 107
Dayton, OH 45409

Directions to our office

Copyright 2010 FlexBank, Inc.
All rights reserved.
Reproduction in whole or in part without permission is prohibited.

 Flexible Spending Account Forms Online

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  • All forms are in Adobe .pdf format.
  • Click on the form you want below. A separate window will open with the selected form displayed.
  • Either print the form or save a copy to your computer.

Employers may save these to your hard drive, then print the form(s) and distribute them to your employees as needed. Employees must submit Enrollment and Change forms to their employer, not to FlexBank.

 

Standard Enrollment Form Flexible Spending Account Enrollment Form
 
Direct Deposit Form Direct Deposit Form
 
Budgeting Worksheet Expense Estimate Worksheet
 
Change of Status Form Change of Status Form
 
General Claim Form Flexible Spending Account Claim Form
 
Dependent Care Claim Form Dependent Care Receipt and Claim Form
 
COBRA FAQs Cobra Frequently Asked Questions
 
COBRA Notices Model General Notice and Model Election Notice