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Get Ca Archdiocese Of San Francisco Flexible Spending Arrangement Enrollment Form 2020-2024

Ormation Please write legibly to ensure proper enrollment Last Name, First Name SSN / Employee ID # Home Address (Street, City, State, Zip Code) Date of Birth Phone Number Email Address Effective Date Department Name Benefit Elections Section 125 Benefit Yes/No Annual Election Health Care FSA Maximum of $2,700.00 per plan year Yes No $ Day Care FSA Maximum of $5,000.00 per plan year (or $2,500 if you re married and filing taxes separately) Yes No $.

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