Use this form to enroll in health and/or dependent care flexible spending accounts for the plan year that runs July 1, 2017, through June 30, 2018.
PLEASE NOTE: You must download the form and save it to your computer to copmlete the digital signature. Viewing the form in a web browser will not allow a digital signature.
Revision date: 04/21/2017
Submit paper form to Benefits Office, 112 Scovell Hall