Medical Reimbursement and/or Dependent Care Assistance Form

This is your election form for the year 2015. This form is used to specify an amount for Medical Reimbursement and/or a Dependent Care Assistance account. The election must be made before the calendar year begins. This form must be received by the Office of Human Resources no later than December 31, 2014.

If you have any questions, please call the Office of Human Resources at extension 4380.

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