Form Clm-110 Dependent Care Flexible Spending Account Claim Form - Highmark Blue Cross Blue Shield Delaware

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Dependent Care Flexible Spending
Account Claim Form
INSTRUCTIONS:
1. Please see the reverse side for Employee Certification and Definitions and Special Rules.
2. Please PRINT all requested information and be sure to SIGN reverse side.
3. Please retain a copy of this completed form and documentation for your records.
PAYMENT OR REIMBURSEMENT OF DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT CLAIMS ARE SUBJECT TO THE
PROVISIONS OF YOUR EMPLOYER’S PLAN DOCUMENTS AND APPLICABLE LAWS AND REGULATIONS.
Employee’s Name - Last, First, Middle Initial
Employee’s Social Security Number
Martial Status
q
q
Single
Married
q
q
Divorced
Widowed
q Check this box if this is a new address.
Address
If you checked married, is your
spouse employed?
q
q
Yes
No
Daytime Telephone Number - Include Area Code
Employer
Please submit this form to request reimbursement for claims for
Provider’s address including street address, city, state, and zip code.
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dependent day care/household services after the expense has been
Provider’s daytime telephone number, including area code.
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incurred and the service period has ended.
Employee’s name.
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Either the provider must complete the Provider Information and Certification
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Name of dependent for whom care/household services were provided.
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Section below or you must attach documentation from the provider.
Service period including beginning and ending dates.
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Separate documentation must include the following:
Amount provider received for services.
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Provider’s complete name.
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Type of services—whether dependent day care or household services.
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Provider’s taxpayer identification number, unless it is a tax-exempt
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If you have any questions:
organization. For an individual, it is the individual’s social security
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number or taxpayer identification number. For an organization, it is the
organization’s employer identification number. For a tax-exempt
organization described in Internal Revenue Code section 501(c)(3),
such as a school or church, write “tax-exempt” in the space provided.
FULL NAME OF DEPENDENT
DEPENDENT’S
DEPENDENT’S
RELATIONSHIP
DATES OF CARE
REIMBURSEMENT
FOR WHOM CARE WAS PROVIDED
SOCIAL SECURITY NUMBER
BIRTH DATE
TO EMPLOYEE
FROM
TO
REQUEST AMOUNT
$
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$
Total Reimbursement Requested:
PROVIDER INFORMATION AND CERTIFICATION SECTION
Provider’s Name
Taxpayer Identification Number
Amount Received for:
Day Care Services:
$ __________________
Provider’s Address
Daytime Telephone Number–Include Area Code
Household Services:
$ __________________
I certify that:
number or my individual taxpayer identification number. If I am an
organization, then it is my employer identification number. If I am a tax-
For the claim shown above, I provided the services for dependent day
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exempt organization described in Internal Revenue Code section
care or household services for the person listed on the dates shown.
501(c)(3), such as a school or church, I have written “tax-exempt” in the
I have received the amount indicated in the space labeled “Amount
space provided for the taxpayer identification number.
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Received for Day Care/Household Services. ”
If I am a dependent day care center, (i.e., a facility that provides care for
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I am providing my IRS taxpayer identification number in the space
more than 6 individuals not residing at the facility), the center complies
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labeled above, unless I am a tax-exempt organization. If I am an
with all applicable state and local laws and regulations, including
individual, my taxpayer identification number is either my social security
licensing requirements.
Provider’s Signature:
Date: _______/_______/_______
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a claim containing any false, incomplete or misleading information may be guilty of a felony.
PLEASE READ AND SIGN REVERSE SIDE.
CLM-110 (5-12)

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