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Get Fsa1 2005

on the reverse of this form. 2. Read the Certification For Reimbursement, sign and date the form. Make a copy of this form and any documents you send for your records. 3. All reimbursement requests for a plan year made during the following year must be postmarked prior to the filing deadline, which is specified in your plan documents. 4. Mail (or fax) the form to: FSA Customer Service Center • P.O. Box 981178 • EL PASO TX 79998-1178 • Phone: 800-842-2026 • FAX: 915-781-1085 PART 1 EM.

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