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PART I - MEMBER COMPLETES THIS SECTION TO …
PART I - MEMBER COMPLETES THIS SECTION TO SUBSTANTIATE ENTITLEMENT TO FSA 5. TYPE II (X as applicable) FSA-T (Temporary) FSA-R (Restricted) FSA-S (Ship) 6. COMPLETE CURRENT ADDRESS(ES) OF DEPENDENT(S) 8. I CERTIFY TO THE FOLLOWING FACTS (X applicable box(es)) a. I am not divorced or legally separated from my spouse. b.
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PART I - MEMBER COMPLETES THIS SECTION TO …
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