Forms for Plan Year September 2021 - August 2022
- Participating Employers
- Plan Brochure
- Application Letter
-
Application Form
- Direct Deposit
- W-4 Form
-
Child Care
- Informal Child Care: Proof Of Payment
- Preschool, School-age, Youth: Proof Of Payment
- Provider (Purple) Form ---- aka Child Care Qualification Form
-
Elder and Disabled Care
- Proof Of Payment
- Doctors (Green) Form ---- aka Elder/Disabled Relative Qualification Form
- Eligibility Criteria
- College Prep & Counseling
- Benefit Affidavits (English Only)
Staff
Director – Louise Rush
Program Coordinator –
Yuritzy Rodriguez
Payment Coordinator –
Beatrice Mai
Hours
Monday & Wednesday
8:30 AM – 4:45 PM
Phone
(415) 864-0506
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