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 - Withholdings

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

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

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

Flexible Spending Account 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

FSA 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 Debit 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 requires a one-time $5.00 activation fee. Make checks payable to Savers Administrative Services and submit with completed request form.)

Informational Documents

IIAS Participating Merchants - list of merchants who will participate in the new IIAS approval system. Learn more about IIAS from our IIAS Announcement and FAQ document.

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

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

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

COBRA Forms

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

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