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FLEXIBLE SPENDING ACCOUNTS (FSA's) Company Payroll: Bus HQ Rail Employee #: Effective Date: Union Nonunion Check One: Open Enrollment New Enrollment Change Cancellation Name (Last, First, M.I.) Birthdate
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FSA NJ FSAs Birthdate IRC revocation Reimbursement pre Enrollment Healthcare UNUSED waived earnings revoked Cancellation elect accordance HQ guidelines DEFINED reduction spouse

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