Ipg Flex Plan Reimbursement Claim Voucher
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1
2IPG FLEX PLAN
REIMBURSEMENT CLAIM VOUCHER
EMPLOYEE NAME: ___________________________________ SOCIAL SECURITY #:______________
MAILING ADDRESS: __________________________ CITY: ______________ STATE: _____ ZIP CODE: ___________
EMPLOYER: _________________________________ PLAN YEAR: ________
_______________________________________________________________________________________________________
Please read the Instructions on the back of this form and the FSA Rules in your SPD before completing this voucher.
MEDICAL REIMBURSEMENT ACCOUNT CLAIMS
Name of Person
Date Service
Description of Service including
Net Claim
Service Covers
Performed
Name of Service Provider
Amount
______________
_________
____________________________________________
$_________
____________________________________________
______________
_________
____________________________________________
$_________
____________________________________________
______________
_________
____________________________________________
$_________
____________________________________________
______________
_________
____________________________________________
$_________
____________________________________________
______________
_________
____________________________________________
$_________
____________________________________________
TOTAL MEDICAL REIMBURSEMENT CLAIM $_________
DEPENDENT CARE ACCOUNT CLAIMS:
Name of
Dates of Service
Service Provider Name and Address
Claim
Dependent(s)
with Taxpayer ID Number
Amount
______________
_________
____________________________________________
$_________
____________________________________________
____________________________________________
______________
_________
____________________________________________
$_________
____________________________________________
____________________________________________
______________
_________
____________________________________________
$_________
____________________________________________
____________________________________________
TOTAL DEPENDENT CARE CLAIM $_________
Please Read Carefully
I request payment for these expenses from my flexible spending account(s). I certify that the above information is a true and
accurate statement of unreimbursed expenses incurred by me or my eligible dependents on the date(s) indicated, and were
incurred while I was covered under my employer s Plan. These expenses have not been nor will ever be reimbursed by another
source or claimed on my personal income tax return. I understand that I may be liable for payment of all related taxes including
Federal, State and/or City income tax on the amounts paid for any expense improperly claimed under the Plan.
Signature: ___________________________________ Date: ____________________ Email:__________________________
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