Dependent Care Fsa Claim Form - Reimbursement Form - 2017 Page 3
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1
2
3USE THIS PAGE FOR ADDITIONAL DEPENDENT CARE EXPENSES.
FDFTFWF
SECTION 4: YOUR INFORMATION (ABBREVIATED)
SOCIAL SECURITY NUMBER OR EMPLOYEE ID (NO DASHES)
EMPLOYEE LAST NAME
EMPLOYEE HOME ZIP CODE
SECTION 5: YOUR ADDITIONAL DEPENDENT CARE EXPENSES
EXPENSE 2
START DATE OF SERVICE (MMDDYY)
PROVIDER TAX ID OR SSN (ENTER ALL 9’s IF TAX-EXEMPT)
REQUESTED AMOUNT (DOLLARS . CENTS)
.
$
END DATE OF SERVICE (MMDDYY)
RECEIPT ATTACHED?
YES
NO
DEPENDENT #1 DATE OF BIRTH (MMDDYYYY)
DEPENDENT #1 NAME
DEPENDENT #2 DATE OF BIRTH (MMDDYYYY)
DEPENDENT #2 NAME
DEPENDENT #3 DATE OF BIRTH (MMDDYYYY)
DEPENDENT #3 NAME
AFFIDAVIT:
Your day care provider only needs to sign this if you do not have supporting documentation, such as an itemized receipt.
I hereby certify that I provided adult or child day care services to the above individuals in accordance with the amounts and dates that are requested.
PROVIDER’S SIGNATURE
DATE
EXPENSE 3
START DATE OF SERVICE (MMDDYY)
PROVIDER TAX ID OR SSN (ENTER ALL 9’s IF TAX-EXEMPT)
REQUESTED AMOUNT (DOLLARS . CENTS)
.
$
END DATE OF SERVICE (MMDDYY)
RECEIPT ATTACHED?
YES
NO
DEPENDENT #1 DATE OF BIRTH (MMDDYYYY)
DEPENDENT #1 NAME
DEPENDENT #2 DATE OF BIRTH (MMDDYYYY)
DEPENDENT #2 NAME
DEPENDENT #3 DATE OF BIRTH (MMDDYYYY)
DEPENDENT #3 NAME
AFFIDAVIT:
Your day care provider only needs to sign this if you do not have supporting documentation, such as an itemized receipt.
I hereby certify that I provided adult or child day care services to the above individuals in accordance with the amounts and dates that are requested.
PROVIDER’S SIGNATURE
DATE
USE AN ORIGINAL FORM (NOT A PHOTOCOPY)
FDFTFWF
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