Savers Admin Payroll and Benefits Forms

1099 Info/Change Form

Complete for all new 1099 contractors.

Download: 1099 Contractor Info Form

Bonus Check Request Form

Use this form to request bonus checks.

Link: Bonus Check Request Form

COBRA Qualifying Event Notification Form (FSA Only)

Download: COBRA Qualifying Event Notification Form

Employee Info/Change Form

Complete for all new employees or for any demographic changes.

Download: Employee Info/Change Form

Evolution Remote Download Request Form

Request download instructions for Evolution’s Remote Client, our desktop payroll software. (For current clients only.)

Link: Evolution Remote Download Request Form

FSA Benefit Card Request Form

Request additional FSA debit cards for your spouse or dependent child. (If you need to replace a lost card, please contact us at flex@saversadmin.com.)

Download:FSA Benefit Card Request Form

FSA Change in Status Form

Report IRS-approved status changes.

Download: FSA Change in Status Form

FSA Dependent Care Account New Enrollee Worksheet

Calculate annual election for dependent care.

Download: FSA Dependent Care Account New Enrollee Worksheet

FSA Dependent Care Claim Form

Request reimbursement for your eligible dependent care expenses.

Download: FSA Dependent Care Claim Form

FSA Employee Guide

Request a full copy of our Flexible Spending Account employee guide.

Info Link: FSA Employee Guide

FSA/HRA Direct Deposit Authorization Form

Add or change direct deposits for flex or HRA.

Download: FSA/HRA Direct Deposit Authorization Form

FSA Medical Claim Form

Request reimbursement for your eligible medical expenses.

Download: FSA Medical Claim Form

FSA Medical New Enrollee Worksheet

Calculate annual election for medical FSA.

Download: FSA Medical New Enrollee Worksheet

FSA Participant Enrollment Form

Enroll in your company’s flex program.

Download: FSA Participant Enrollment Form

HRA Claim Form

Request reimbursement for eligible HRA (Health Reimbursement Account) expenses.

Download: HRA Claim Form

NC-4 EZ Form

Employees should use this form if they plan to claim the NC standard deduction and claim no tax credits or only the credit for children, if they qualify to claim exempt status, or if they prefer not completing the extended Form NC-4.

Download: NC-4 EZ Form

NC-4 Form

Extended withholding form which may provide more precise withholding figures, but will require historical tax return information and estimation of 2014 income, deductions, and credits from the employee.

Download: NC-4 Form

W-4 Form

Federal withholding form and worksheet for employees.

Download: W-4 Form

W-9 Form

Federal document used to obtain tax information for contractors and freelancers.

Download: W-9 Form

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