Plan year July 1, 2021 through June 30, 2022
Use this form to enroll in health and/or dependent care flexible spending accounts (FSA). You must download the form and save it to your computer to complete the digital signature. Viewing the form in a web browser will not allow a digital signature.
Revision date: 04/23/2021
Submit paper form to Benefits Office, 112 Scovell Hall, Lexington KY 40506-0064