EBO Forms

Election/Change (Medical, Dental, Life, FSA)

• County of Sacramento Election/Change Form

Health and Dental - Active Employees

• Deletion of Dependent(s)
• Blue Shield High Deductible Non-Network Claim Form

Health Savings Account

• Wells Fargo HSA Enrollment Form - Complete and return to the Employee Benefits Office
• Wells Fargo HSA Designation and Change of Beneficiary Form - Complete and return to Wells Fargo
• Health Savings Account Election Change Form – return completed form to the Employee Benefits Office
• Health Savings Account Reimbursement Request Form - Wells Fargo

Flexible Spending Account

• Flexible Spending Claim Form (2010)
• Dependent Care Contract Form
• Orthodontia Contract Form
• Flexible Spending Direct Deposit Authorization Form
• Medical Reimbursement Account Worksheet
• Dependent Care Reimbursement Account Worksheet

Deferred Compensation

• Please see Deferred Compensation website for forms.

Inquire about the availability of documents in alternate formats.