INSTRUCTIONS: ALABAMA FLEXIBLE SPENDING ACCOUNT ENROLLMENT APPLICATION (Form PEEHIP FSA)

To enroll in an Alabama flexible spending account administered by the public education employer's health insurance plan, file a form PEEHIP FSA. This document can be obtained from the website of the Retirement Systems of Alabama.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 1: The first section concerns the subscriber. On the first line, enter your Social Security number or PiD number, first name, middle name or initial and last name.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 2: On the second line, enter the subscriber's mailing address, city, state and zip code.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 3: On the third line, enter the subscriber's date of birth, home phone number and work phone number. Indicate whether you are male or female with a check mark.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 4: On the fourth line, indicate whether you are single, married, divorced, legally separated or widowed with a check mark.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 5: On the fifth line, enter your employer or school system, email address and date of employment.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 6: The next section concerns healthcare flexible spending accounts. Indicate whether you wish to enroll in this program with a check mark.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 7: If enrolling, indicate whether you choose a flex debit card, traditional reimbursement or manual reimbursement with a check mark.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 8: Enter your monthly and annual contribution amounts.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 9: The next section concerns dependent day care flexible spending accounts. Indicate whether you wish to enroll in this program with a check mark.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 10: Enter your monthly contribution amount on the first blank line if enrolling.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 11: Enter your annual contribution on the second blank line.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 12: Enter your signature on the third blank line.

Alabama Flexible Spending Account Enrollment Application PEEHIP FSA Step 13: Enter the date on the last blank line.