EBS/Atlanta Forms

PDF format

(Requires Adobe Acrobat Reader)

• Flexible Spending Account (FSA) Claims
• Take Care Transmittal Form
• Take Care Card Request Form
• Take Care IIAS Merchant List
• Qualified Transportation Benefit (QTB) Claims
• Revocation Request
• Check Reissue Agreement
• Direct Deposit Form
• COBRA/Retiree Automatic Draft Form -- Direct Pay
• COBRA Termination Request
• COBRA Change Request
• List of merchants that have either been certified as IIAS compliant or soon will be compliant to accept all FSA debit cards

Microsoft Word format

• Flexible Spending Account (FSA) Claims
• Revocation Request

Mailing Labels

• Avery 5160

• Form W-10 (Dependent Care Provider Certification)
• Publication 502 (Medical and Dental Expenses)
• Publication 503 (Child and Dependent Care Expenses)

• Eligible and Non-Eligible Over-the-Counter Items
• Notice of Privacy Practice