- (file: 2016-limited-purpose-fsa-request-form_.pdf text: 2016 Limited-Purpose FSA Request Form) - (file: 2017_limited_purpose_fsa_claim_form-1.pdf text: 2017 Limited-Purpose FSA Request Form) - (file: expenses-eligible-for-reimbursement-from-a-limited-purpose-fsa.pdf text: Expenses Eligible For Reimbursement For A Limited-Purpose FSA) - (file: expenses-eligible-for-reimbursement-for-a-limited-purpose-fsa-spanish.pdf text: Expenses Eligible For Reimbursement For A Limited-Purpose FSA—Spanish)