Form Gc-14046 - Dependent Care Flexible Spending Account Claim Form
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Mail to:
ExxonMobil Pre-Tax Spending Plan
Aetna, Inc.
Dependent Care Flexible Spending Account
PO Box 981106
Claim Form
El Paso, TX 79998-1106
Fax to:
1-859-455-8650 (within USA)
1-859-425-3370 (outside USA)
Telephone: 1-800-255-2386
If overseas, 210-366-2416 (collect)
Hours: 8:00 a.m. to 6:00 p.m. CT
See instructions on reverse side.
1. Plan
FSA Control Number
721002
Information
ExxonMobil Pre-Tax Spending Plan
2. Employee
Member ID Number or Social Security Number
Name
Daytime Telephone Number
(
)
Information
Address (include ZIP Code)
Home Telephone Number
(
)
3. Dependent
Name
Relationship to Employee
Date of Birth (MM/DD/YYYY)
Age
Information
Spouse
Child
Other
Date(s) of Service (MM/DD/YYYY)
From
Thru
Total Amount Submitted $
Name
Relationship to Employee
Date of Birth (MM/DD/YYYY)
Age
Spouse
Child
Other
Date(s) of Service (MM/DD/YYYY)
From
Thru
Total Amount Submitted $
Name
Relationship to Employee
Date of Birth (MM/DD/YYYY)
Age
Spouse
Child
Other
Date(s) of Service (MM/DD/YYYY)
From
Thru
Total Amount Submitted $
Name
Relationship to Employee
Date of Birth (MM/DD/YYYY)
Age
Spouse
Child
Other
Date(s) of Service (MM/DD/YYYY)
From
Thru
Total Amount Submitted $
Name
Relationship to Employee
Date of Birth (MM/DD/YYYY)
Age
Spouse
Child
Other
Date(s) of Service (MM/DD/YYYY)
From
Thru
Total Amount Submitted $
4. Provider
Provider Name
Social Security Number or Tax ID Number of Provider
Information
Address of Provider
Attach supporting documentation (i.e., itemized statement from care provider).
5. Employee
I certify that I have incurred the above expenses and declare that I have not and will not claim credit for
Certification
these expenses on my individual income tax returns.
I further certify that I have read and understand the limitations on reimbursement from my Dependent Care
Reimbursement Account in my summary plan description and on the reverse side of this form and that I
am eligible to receive benefits under this program. I certify that the above eligible dependent care expenses
have been paid for the care of a qualified individual(s).
Employee Signature X
Date
GC-14046 (4-14)
999-0088E
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