Flexible Spending Account Continuation Election Form

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Summary

This form must be returned to ETF, by mail or at the outside drop box, along with your payment.

Employers must issue this notice to employees within 14 days of becoming aware of a qualifying event that will cause an employee to lose eligibility to participate in the flexible spending account (FSA) or limited purpose FSA program(s).

If you would like to complete the form electronically, be sure to first download the form, complete using Acrobat Reader, and save.

Note: ETF is unable to assist with Adobe Acrobat Reader technical or compatibility issues. If you need assistance, please visit Adobe’s help site.