In an effort to make things easier for you, Savers Administrative Services has some common forms available for download. All forms are in Adobe Acrobat PDF format. If you do not have Acrobat Reader, you may download a free copy from Adobe Systems, Inc.

Claim Forms

FSA Medical / Healthcare Claim Form - for FSA account reimbursement of medical and/or health care expenses

FSA Dependent Care / Day Care Claim Form - for FSA account reimbursement of child care expenses

Health Reimbursement Arrangement (HRA) Claim Form - for HRA account reimbursement of insurance deductible expenses

Payroll

Federal W-4 Form - IRS form; provide to your employer so they can withhold the correct federal income tax from your pay

North Carolina NC-4 Form - state form for NC residents; provide to your employer so they can withhold the correct North Carolina state income tax from your pay

Form I-9, Employment Eligibility Verification - used by employers to document that each new employee (both citizen and non-citizen) hired after November 6, 1986, is authorized to work in the United States

Employee Payroll Information Form - used by employers to report new hires or payroll changes to Savers payroll department

Employee Payroll Direct Deposit Authorization Form - used by employees to set up direct deposit of their payroll

Other FSA and HRA Forms

FSA Direct Deposit Authorization - to sign up for direct deposit of manual claim reimbursements for medical FSA and Dependent Care accounts

HRA Direct Deposit Authorization - to sign up for direct deposit of HRA claim reimbursements

FSA Change in Status Form - to request a change in your FSA election when you have a qualifying event

FSA Medical / Healthcare New Enrollee Worksheet - to help you calculate your annual contribution amount

Dependent Care / Day Care New Enrollee Worksheet - to help you calculate your annual contribution amount

Employee Participation Form - to sign up for your employer's FSA Plan

Dependent Benefit Card Request Form - use to add an additional benefit card to your Flex account - great for your spouse or dependent student in college. (Your FSA plan must include the benefit card option from your employer. Each additional card has a one-time $5.00 activation fee. Make checks payable to Savers Administrative Services and submit with completed request form.)

COBRA Forms

Qualifying Event Notification - for employers; use to submit notice of a qualifying event to Savers

Notice of New Employee - for employers; use to inform Savers of a new-hire at your company

Informational Documents

IIAS Announcement - information about the Inventory Information Approval System (IIAS) point-of-sale approval system for purchase of FSA eligible products.

Instructions for Setting Up Your FSA Online Account - check your balance online, view transactions, and more

Eligible and Ineligible Flex Account Expenses - list of items that may or may not be purchased with FSA funds

"Remember SAVERS" - hints and tips regarding the use of your FSA account and your FSA benefit card